Betsy Nicoletti, 1/31/19
Hospitalists became a recognized specialty by CMS starting in April of 2017, and we now have frequency E/M data for 2017. It’s not a full year, and there are probably many physicians who did not switch their specialty designation, but it’s a start. 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 2017, the first year of the hospitalist specialty designation, released in late 2018.
Initial inpatient services, 99221–99223
| Initial inpatient 2017 |
Family Medicine | IM | Hospitalist |
| 99221 | 7.12% | 5.25% | 4.62% |
| 99222 | 35.34% | 27.23% | 22.17% |
| 99223 | 57.55% | 67.52% | 73.22% |
For hospitalists, 73% of their initial inpatient services are billed as level 3 visits, compared to 57% for family medicine and 67% 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 64% of their visits, cardiologists bill 99223 for 53% of their visits. Physicians who are designated as critical care/intensivists bill 63% of their initial inpatient visits as 99223s. Infectious disease physicians bill 51% of their initial inpatient services as 99223s. Interventional cardiologists bill 54% of their initial inpatient services as 99223s. In fact, their frequency of 99223s is the highest of any specialty.
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 | 2017 | 2000 | 2017 | ||
| 99231 | 26.21% | 5.48% | 99231 | 33.32% | 8.55% |
| 99232 | 56.48% | 60.71% | 99232 | 53.98% | 62.43% |
| 99233 | 17.13% | 33.81% | 99233 | 12.70% | 29.02% |
Between 2000 and 2017, 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 2017 |
Family Medicine | IM | Hospitalist |
| 99231 | 8.55% | 5.48% | 4.07% |
| 99232 | 62.43% | 60.71% | 57.18% |
| 99233 | 29.02% | 33.81% | 38.75% |
Observation, and admission and discharge on the same day, 99218—99220, 99234—99236
| OBS admissions 2017 |
Family Medicine | IM | Hospital-ist |
| 99218 | 8.83% | 5.09% | 3.44% |
| 99219 | 37.18% | 27.44% | 27.65% |
| 99220 | 53.99% | 67.47% | 68.91% |
| Adm/DC same day 2017 |
Family Medicine | IM | Hospitalist |
| 99234 | 12.82% | 10.14% | 7.41% |
| 99235 | 47.43% | 35.78% | 34.11% |
| 99236 | 39.75% | 54.09% | 58.48% |
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?
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