Hospitalists became a recognized specialty by CMS starting in April of 2017, and we now have frequency E/M data for the specialty. There are probably still physicians who have not switched their specialty designation. Physicians self-elect their specialty designation with Medicare and other payers. Many hospitalists are family medicine or internal medicine physicians by training, working as hospitalists.
The data below is from 2019, released in late 2020.
Initial inpatient services, 99221–99223
| Initial inpatient | Family Medicine | IM | Hospitalist |
| 99221 | 6.56% | 4.80% | 3.84% |
| 99222 | 34.22% | 226.59% | 19.59% |
| 99223 | 59.22% | 68.61% | 76.57% |
For hospitalists, 76% of their initial inpatient services are billed as level 3 visits, compared to 59% for family medicine and 68% for internal medicine. I review the E/M data each year, and this rate of level three initial hospital services is one of the highest of any specialty group.
Pulmonary doctors bill 99223 for 66% of their visits, cardiologists bill 99223 for 54% of their visits. Physicians who are designated as critical care/intensivists bill 62% of their initial inpatient visits as 99223s. Infectious disease physicians bill 53% of their initial inpatient services as 99223s.
Initial hospital services require all three key components, a comprehensive history, comprehensive exam and high complexity MDM. If I were involved with a hospitalist group, I would certainly track this metric by physician and include high level E/M services in my audit plan for the year.
Subsequent hospital services, 99231—99233
Before we look at subsequent hospital services by specialty, let’s turn back the clock. The earliest frequency data I’ve saved is 2000.
| Internal medicine, subsequent hospital visits | Family medicine, subsequent hospital visits | ||||
| 2000 | 2019 | 2000 | 2019 | ||
| 99231 | 26.21% | 4.90% | 99231 | 33.32% | 11.76% |
| 99232 | 56.48% | 58.47% | 99232 | 53.98% | 36.17% |
| 99233 | 17.13% | 36.63% | 99233 | 12.70% | 52.07% |
Between 2000 and 2019, the frequency of using 99231 dropped for both specialties, and the frequency of using the highest-level subsequent hospital visit increased for both specialties, considerably. The middle code, 99232, the “safe, fly-under-the-radar” code increased for both specialties.
Now, let’s look at current data and compare FM, IM and hospitalists. Hospitalists have the lowest frequency of using 99231, and the highest frequency of using 99233. Subsequent visits require only two of the three key components.
| Subsequent | Family Medicine | IM | Hospitalist |
| 99231 | 7.44% | 4.90% | 3.56% |
| 99232 | 61.41% | 58.47% | 53.32% |
| 99233 | 31.15% | 36.63% | 43.13% |
Observation, and admission and discharge on the same day, 99218—99220, 99234—99236
| OBS admissions | Family Medicine | IM | Hospitalist |
| 99218 | 7.44% | 4.59% | 2.83% |
| 99219 | 36.60% | 26.89% | 24.17% |
| 99220 | 55.96% | 68.52% | 72.99% |
| Adm/DC same day 2018 |
Family Medicine | IM | Hospitalist |
| 99234 | 11.55% | 8.80% | 5.19% |
| 99235 | 45.35% | 35.38% | 33.92% |
| 99236 | 43.10% | 55.82% | 60.89% |
These are consistent with inpatient admissions. Hospitalists report higher levels of initial services for observation admissions, and for admission and discharge on the same calendar date. It does lead to the question, are hospitalists managing sicker patients, or documenting them more completely or billing them at too high a level?
Applying the 2021 office visit guidelines is challenging. And, although we focus a lot on data, many visit levels will be selected based on the number and complexity of problems, and risk.
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