Inpatient Stroke Case Studies
Inpatient E/M Case Studies
Case study of a stroke patient at varying visit levels to better understand code selection for inpatient encounters under the revised guidelines for 2024.
67-year-old Female with Stroke
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: Critical Care (99291)
A 67-year-old woman with hypertension and diabetes presents to the emergency department with abrupt onset of left hemiparesis 45 minutes ago.
Pre-evaluation: Discussed presentation and vital signs with ED provider (3 mins).
Face-to-face evaluation: Performed medically appropriate history and exam. She has a dense left hemiparesis and an NIH Stroke Scale score of 8. Thrombolysis safety criteria reviewed (7 mins).
Post-evaluation: Non-contrast head CT, CTA of head and neck, and lab results reviewed in the ED. Case discussed with ED provider and thrombolysis recommended. Consultation documented in the ED (25 mins).
Total time: 35 minutes.
| Problems Addressed | Data Reviewed | Patient Management Risk of Complications |
| Acute impairement of a vital organ system with high risk of deterioration | Independent hisotry, review of vitals and lab data, review of head CT and other imaging | Recommendation for thrombolysis |
| High/Critical | High/Critical | High/Critical |
Critical Care Coding
According to the 2024 CPT code set, a provider may bill for critical care when the following requirements are met:
- A critical condition: one that acutely impairs a vital organ system with a high probability of imminent or life-threatening deterioration. This includes, for example, central nervous system failure.
- Direct delivery of critical care: high complexity decision-making to assess, manipulate, and support vital systems to treat organ system failure or prevent further life-threatening deterioration.
- At least 30 minutes of time spent solely in the care of the patient. It does not need to be continuous, and it includes both time at the bedside and time spent on the same floor or unit engaged in work directly related to the patient’s care (e.g., documenting critical care, reviewing test results, discussing care with other providers, obtaining history, or discussing treatments or treatment limitations with surrogates when the patient lacks the capacity to do so).
Specific critical care credentials are not required to bill critical care. Critical care is usually provided in a critical care area such as an intensive care unit or emergency department, but this is not always the case (for example, critical care provided to a deteriorating patient in a non-critical care unit).
Other examples of critical care might include:
- Evaluating a patient with status epilepticus and prescribing anti-epileptic drugs or sedative infusions,
- Evaluating a patient with acute respiratory failure from neuromuscular disease and prescribing plasmapheresis,
- Evaluating a patient with coma after cardiac arrest and discussing prognosis, treatment, and goals of care with surrogates (documenting the patient’s lack of capacity to participate)
| Condition | Treatment | Time |
| Acute ischemic stroke | Thrombolysis | 35 minutes |
Critical care, 30-74 minutes
CPT 99291 is justified based on the above documentation, although E&M codes (e.g., 99223) associated with fewer wRVUs and lower reimbursement could be used as well.
Day 2: Subsequent Hospital Inpatient Care
Pre-rounds: Reviewed vitals, labs, and studies (LDL, Hemoglobin A1c, EKG, TTE). Review and document independent interpretation of MRI (8 mins).
On Rounds: Performed medically appropriate history and exam. The patient’s symptoms and findings improved somewhat overnight. Patient counseled about stroke evaluation and secondary prevention (10 mins).
Post-rounds: Order atorvastatin, order diabetes consult for management of diabetes. Document discussion with case management possible need for acute inpatient rehabilitation. Documentation completed (10 mins).
Total time: 28 minutes
| Problems Addressed | Data Reviewed | Patient Management Risk of Complications |
| One acute illness that poses a threat to life or bodily function | Review of test results Independent interpretation of tests Discussion of management |
Prescription drug management |
| High | High | Moderate |
| Time | MDM |
|
Total time of visit (includes all time on pre-rounds, on round, and post-rounds): 28 minutes Subsequent encounter, level 1: ≥ 25 minutes CPT 99231 |
Problems addressed: High Data reviewed: High Risk of complications: Moderate Level 3: High CPT 99233 |
In this situation, billing according to MDM would be associated with higher reimbursement.
Day 3: Discharge Day Management (By Primary Service)
Pre-rounds: Reviewed vitals, daily CBC and BMP, nursing notes and PT/OT notes (5 mins).
On Rounds: Performed medically appropriate history and exam. The patient reports continued slight improvement in symptoms and requests counseling on how complementary and alternative medicine might help manage her chronic conditions (15 mins).
Post-rounds: Prescribe antiplatelet agent, antidiabetic medications, and antihypertensives. Prepare discharge paperwork and document discharge summary (15 mins).
Total time: 35 minutes
| Problems Addressed | Data Reviewed | Patient Management Risk of Complications |
| One acute illness that poses a threat to life or bodily function | Limited | Prescription drug management |
| High | Low | Moderate |
Discharge Day Management Coding (Inpatient or Observation)
Discharge CPTs are selected based on total (face-to-face and non-face-to-face) time, not MDM:
- 99238: 30 minutes or less
- 99239: 31 minutes or more
Discharge CPTs would be used by the primary attending service (e.g., a Neurohospitalist service). Consulting services would continue to choose Subsequent Day codes based on time or MDM.
Discharge Day Management, 31 minutes or more
CPT 99239
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.
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*The Academy recommends always checking private payer policies before rendering procedures or services