Inpatient Seizure Case Studies
Inpatient E/M Case Studies
Case study of a patient presenting with concern for status epilepticus at varying visit levels to better understand code selection for inpatient encounters under the revised guidelines for 2023.
39-year-old Male with Seizures
Total time* for Inpatient E/M in 2023
Refer to the following tables for correct code selection when billing based on time for inpatient E/M Services:
| CPT Code | Time (Minutes) | |
| Initial Hospital Inpatient or Observation Care | 99221 99222 99223 |
40 55 75 |
| Subsequent Hospital Inpatient or Observation Care | 99231 99232 99233 |
25 35 50 |
| Critical Care Services | 99291 99292 |
First 30-74 Each additional 30 |
*Total time includes non face-to-face time on the date of service
DAY 1
39-year-old male with known intractable Lennox-Gastaut syndrome presenting with increased frequency of generalized tonic clonic seizures. He was admitted to the Epilepsy Monitoring Unit and placed on continuous video EEG monitoring.
Pre-rounds : Reviewed history, home medications, labs and studies obtained in ED (CBC with diff, CMP, CT brain WO) as well as review of EEG with Epileptologist. (15 minutes)
On Rounds : Performed medically appropriate history and exam. Decision made to add new medications to current regimen following extensive discussion with family/ care givers. (30 minutes)
Post-rounds : IV medications are ordered. EEG monitoring continued. H&P written. (30 minutes)
|
Problems Addressed |
Data Reviewed | Patient Management Risk of Complications |
|
One chronic illness with severe exacerbation |
3 data elements reviewed |
Prescription drug management |
| High | High | High |
Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.
Day 2
Patient remains drowsy. EEG revealed frequent bifrontal epileptiform discharges and continuous generalized slowing consistent with multifocal epilepsy and mild to moderate encephalopathy but no seizures. Exam improves throughout the course of the day. Plan made to discharge patient home the following day.
Pre-rounds : Reviewed medications, labs including infectious work up sent on admission, and reviewed findings of 24 hours of EEG with Epileptologist. (15 minutes)
On Rounds : Performed medically appropriate history and exam. Decision made to continue new medications following discussion and counseling with family/ caregivers. (20 minutes)
Post-rounds : EEG monitoring discontinued. Progress note written. (15 minutes)
|
Problems Addressed |
Data Reviewed | Patient Management Risk of Complications |
| One chronic illness with not at goal/uncertain prognosis | 3 data elements reviewed | Prescription drug management |
| Moderate | Moderate | Moderate |
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.
Day 3
Patient develops worsening mental status and increasing oxygen requirements. Decision made to transfer the patient to the ICU for progressive hypoxia.
Pre-rounds : Reviewed history, medications, daily labs, chest x-ray reports and EEG findings. Discussions held with Intensivist regarding transfer to ICU and with Epileptologist regarding resuming EEG monitoring. (30 minutes)
On Rounds : Performed medically appropriate history and exam. Discussions held with family/ care givers regarding need for feeding tube placement and possibility for intubation. (30 minutes)
Post-rounds : Feeding tube placed. EEG monitoring resumed. Progress note written. (30 minutes)
|
Problems Addressed |
Data Reviewed | Patient Management Risk of Complications |
| One chronic illness with SEVERE exacerbation | 3 data elements reviewed | Prescription drug management |
| High | High | High |
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.
Day 4
Patient becomes hypotensive overnight and has a rapid escalation in oxygen requirements in the setting of episodes of aspiration and emesis necessitating intubation and vasopressors.
Pre-rounds : Reviewed medications, daily labs, chest x-ray and 24- hour continuous EEG findings with Epileptologist, which reveals frequent electroclinical seizures consistent with status epilepticus. (15 minutes)
On Rounds : Performed medically appropriate history and exam. Reviewed IV medications and dosages. Recommendations given for the addition of new antiseizure medications. Discussed goals of care with family/ caregivers. (20 minutes)
Post-rounds : Antibiotics initiated. EEG monitoring continued. Progress note written. (15 minutes)
|
Problems Addressed |
Data Reviewed | Patient Management Risk of Complications |
| One chronic illness with acute exacerbation | 3 data elements reviewed | Prescription drug management |
| High | High | High |
99291 is critical care, evaluation and management of the critically ill or critically injured patient for the first 30–74 minutes direct delivery of care to a critically ill or injured patient when 1 or more vital organ systems are acutely impaired, A probability of imminent or life-threatening deterioration of the patient’s condition exists.
Disclaimer:The billing and coding information provided by the American Academy of Neurology and its affiliates (collectively, “Academy”) are assessments of clinical information provided as an educational service. The information (1) is not clinical advice; (2) does not account for how private payers cover and reimburse procedures or services*; (3) is not continually updated and may not reflect the most current clinical information (new clinical information may emerge between the time information is developed and when it is published or read); and (4) is not a substitute for the independent professional judgment of the treating provider, who is responsible for correctly coding procedures and services.
Using this information is voluntary. The Academy is providing the information on an “as is” basis and makes no warranty, expressed or implied, regarding the information. The Academy specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. The Academy assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.
*The Academy recommends always checking private payer policies before rendering procedures or services