Skip to content

Billing, Coding & Attestations

Billing, Coding and Attestations:

It is valuable to understand the basics of coding so that we can appropriately bill our patients for our services and avoid either over- or under-coding. See EPIC tip sheet below for how-to instructions.

Inpatient coding rules changed in January 2023. Billing for initial or subsequent care can be done either by medical decision making (MDM) or time basis. There is no distinction between inpatient or observation visit types.

Time based billing is based on all “face-to-face and non-face-to-face in the care of this patient, which includes all pre, intra, and post visit time on the date of service.” preparing to see the patient (e.g., review of tests) obtaining and/or reviewing separately obtained history performing a medically appropriate examination and/or evaluation counseling and educating the patient/family/caregiver ordering medications, tests, or procedures referring and communicating with other health care professionals (when not separately reported) documenting clinical information in the electronic or other health record independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver care coordination (not separately reported)

All documented time should be specific to the E/M visit and not include any procedures billed separately. The attestation .TP03 can be used to appropriately bill by time.

2023 time-based criteria are below:

CPT Code Time (min)
99221 Initial hospital care LOW 40
99222 Initial hospital care MODERATE 55
99223 Initial hospital care HIGH 75
99231 Subsequent hospital care LOW 25
99232 Subsequent hospital care MODERATE 35
99233 Subsequent hospital care HIGH 50

Biling by MDM requires your documentation to support the criteria listed in the chart below. In order to bill the HIGH level of codes, the documentation must meet 2 out of 3 of HIGH criteria in terms of number/complexity of problems, amount/complexity of data and risk of complications, morbidity/mortality. For MODERATE codes, the documentation must meet 2 out of 3 MODERATE criteria. Copy/forward information from previous notes does not count in meeting these criteria.

Level of MDM Number/complexity problems Amount/complexity of data Risk of Complications, Morbidity/Mortality
High 99223 99233 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; 1 acute or chronic illness or injury that poses a threat to life or bodily function (Must meet the requirements of at least 2 out of 3 categories) Category 1: Tests, documents or independent historian(s) - Need 3 •Review of external notes •Review of results of each test •Ordering of each test •Assessment requiring independent historian Category 2: Independent interpretation of tests •Independent interpretation of a test performed by another physician/other HCP; Category 3: Discussion of management or test interpretation •Discussion of management or test interpretation with external physician/other HCP/appropriate source High risk of morbidity from additional diagnostic testing or treatment Examples only: Drug therapy requiring intensive monitoring for toxicity Decision regarding elective major surgery with identified patient or procedure risk factors Decision regarding emergency major surgery Decision regarding hospitalization or escalation of hospital level care ·Decision not to resuscitate or to deescalate care because of poor prognosis ·Parenteral controlled substances
Moderate 99222 99232 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment 2 or more stable, chronic illnesses 1 undiagnosed new problem with uncertain prognosis 1 acute illness with systemic symptoms 1 acute, complicated injury, (Must meet the requirements of at least 1 out of 3 categories) Category 1: Tests, documents or independent historian(s) - Need 3 •Review of external notes •Review of results of each test •Ordering of each test •Assessment requiring independent historian Category 2: Independent interpretation of tests •Independent interpretation of a test performed by another physician/other HCP; Category 3: Discussion of management or test interpretation •Discussion of management or test interpretation with external physician/other HCP/appropriate source Moderate risk of morbidity from additional diagnostic testing or treatment Examples only: Prescription drug management Decision regarding minor surgery with identified patient or procedure risk factors Decision regarding elective major surgery without identified patient or procedure risk factors Diagnosis or treatment significantly limited by social determinants of health

Other coding tips: Inpatient discharge day codes are time based only. A 99239 is billed for > 30 minutes spent on discharge activities. - Prolonged service modifiers (99418/G0316) can be used for each 15 minutes of total time in excess of 15 minutes > than the HIGH billed code spent with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time. - Critical care codes should be used for “the direct delivery by a physician of medical care for a critically ill or critically injured patient. Critical illness acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition.” These codes can be used when over 30 minutes are spent in critical care and can be used by physicians or NPPs. - If you spend greater than 30 minutes with a septic patient, at a rapid response or code, etc., remember to use the critical care language for coding. - Location does not matter, only the condition of the patient and the time spent in care of that patient. - Use the EPIC Smartphase .TP36 for time based critical care billing.

Shared Visits with APPs: Our APPs are licensed providers and may care for patients daily without physician co-signature. Discharge summaries do require co-signature per UNC by-laws.

For complicated patients, they may request assistance from their team physician. If the patient is seen and assistance is given, attendings may co-sign an APP note or attest for a shared visit, which may provide additional reimbursement. A split or shared visit is an E/M visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group. Payment is made to the practitioner who performs the substantive portion of the visit.

During the transitional years, 2022 and 2023, the substantive portion can be one of the three key E/M visit components (history, exam, or medical decision-making [MDM]), or more than half of the total time spent by the physician and NPP performing the split or shared visit. In other words, for calendar year 2022 and 2023, the practitioner who spends more than half of the total time, or performs the history, exam, or MDM can be considered to have performed the substantive portion and can bill for the split or shared E/M visit.

Beginning January 1, 2024, substantive portion means more than half of the total time spent by the physician and NPP performing the split or shared visit.

Resident attestations: Resident notes should be attested by the teaching physician. There are 3 options to appropriately bill with a resident documented note: Teaching attending may independently perform the required elements to support the visit billing level and link to the resident documentation OR The attending may supervise the resident of the provision of that service and perform critical or key portions of the service OR The resident and attending may see patient separately and the attending perform the critical or key portions of the service during their visit. Use .ATTESTATIONUNCHCS system smart phrase with the E&M INCLUDING RESIDENT/FELLOW menu choice to properly document your participation. Time-based E/M services (e.g. critical-care services, discharge day management, prolonged care, etc.) are excluded from above teaching physician rules.  Resident time does not count towards time spent with patient, the physician must document their own time spent with patient.

Student attestations: Per 2018 CMS policy change, medical student notes can now be used for billing purposes provided that the teaching physician verifies the documentation. The teaching physician must either personally perform or re-perform the physical exam and medical decision making but does not need to re-document. Notes should be attested using the .ATTESTATIONUNCHCS and selecting the MEDICAL STUDENT NOTE from the available list. Attendings at UNC Hospital are not currently approved to bill using PA student notes at this time. Separate notes should be written by the attending for these students.

Billing and Coding EPIC workflow:

Charge Capture Popup Inpatient Workflow

Various billable service note types may require additional action on the part of the MD, Mid-Level Provider or Resident with regard to capturing professional charges. The below steps outline the various scenarios and the action needed.

Charge Capture Popup

A provider MUST be logged in to the appropriate Department (for most providers this is their primary ambulatory clinic department) to receive the correct charge list in the popup box. Inpatient ONLY Providers need to log into their Service [ie Gynecology SVC, Hospitalists, etc.] and NOT a nursing unit or floor. If a provider does not get the correct preference list in their charge popup screen, they should check their log in context first to ensure they are logged in to the appropriate department.

  • When a billable service type note is signed/co-signed/finalized/addended, the Charge Capture window will appear immediately to ensure charges are captured.* This removes the need to navigate to the Charge Capture Activity following each note.

The affected notes are: Progress, Procedure, Consults, Delivery Attendance, Discharge Summary, Global Post-op, H&P and Significant Event.

Each of these notes will need a charge entered, so you must choose a code and file a charge. - Billable notes/services: If it’s a billable service and you feel comfortable coding, then select the appropriate code and file it. In many instances, these will still route to a coder assigned to your service for review. So, you do not need to choose the send to coder option if you are coding your own notes. - Unsure of which Charge to select: If you had not been coding your own charges in Epic previously, then you may select the “Send to Coder” charge. This is the only trigger to send the note to the coders so they can review the note and enter in the appropriate charge. There is no longer a dummy charge being generated behind the scenes. - Non-billable notes/services: If the note/service should not be billed, choose the No Chargeable Visit 99999 code. The code for global post op charges is 99024.

UNC/Chatham Workflow

All MDs/NPs/PAs

  • When the note is signed/cosigned/finalized/addended, the Charge Capture screen will appear
  • Place charges accordingly, click the Button and after ensuring appropriate charge filed
Associating a Diagnosis to the Charge

  • When the charge is selected, it will appear under the Review Selected Charges section. If a diagnosis is linked to the charge, thesymbol will appear in the Dx column and the charge can be filed.

  • If a Diagnosis is not documented, the Dx column will reflect the “unlinked” symbols.

  • To correct this, click on the blue charge name hyperlink in the Description column.

  • To associate a diagnosis that is already listed, check the diagnosis that applies to this charge.
  • If the diagnosis for this charge is not listed, you can put in a new one by going to the Other Diagnosis field. Once you choose the correct diagnosis, it will show in the top section where you can place a checkmark to associate it.

  • Adding the diagnosis on this screen DOES NOT update the patient’s problem list, so you must navigate to the Problem List activity and document the diagnosis there as well.

  • Click .

  • Once you see your charges appear under the “Charges with a Service Date” with today’s date, click to finish.