Cardiology Coding Alert

Improve Your Subsequent Hospital Care Coding

Everything the cardiologist does can contribute to greater MDM

When you find yourself assigning a code for subsequent hospital care, don't limit yourself to 99231. Otherwise, you may raise a payer's red flag and mark your cardiology practice for a future audit.
Physicians generally report 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) more often than any other subsequent hospital care code, according to CMS data. This means either most subsequent hospital visits are low-level services or doctors routinely undercode for inpatient care. As long as your documentation warrants it, you should feel free to report higher-level subsequent hospital care.
Because carriers usually bundle hospital care into postsurgical visits, many cardiologists aren't familiar with the documentation guidelines associated with subsequent hospital care for nonsurgical situations, such as myocardial infarction (MI) or congestive heart failure (CHF). If you pick up the patient's care after another physician - such as a general surgeon - admits the patient to the hospital, you should report from the 99231-99233 code range.
Use the following four tips to ensure you're properly assigning these codes:

1. Learn the Coding Levels

You may believe that reviewing documentation is the first step to determine whether you can increase your inpatient coding levels, but that's actually the second step. If you don't know what constitutes each service level, reviewing the documentation won't help. So educate your practice regarding what CMS requires for each care level.
As a starting point for physician education, coding experts suggest these basic guidelines for the three subsequent hospital care levels:

  • 99231 - Patient is stable, recovering or improving.
  • 99232 - Patient is responding inadequately to therapy or has developed a minor complication.
  • 99233 - Patient is unstable or has developed a significant complication or a significant new problem.

    While the documentation (history, exam, complexity, and maybe time) will ultimately drive the supported service level, these guidelines help illustrate the differences in terms more familiar to cardiologists. Make sure they understand the importance of their documentation.
    If your practice routinely reports 99231 for all subsequent hospital care services, tell your physicians that this might raise red flags with your payers, coding experts say. "Excessive reporting of 99231 would indicate that the practice is routinely downcoding, or the patients should have been discharged earlier," says Bob Lloyd, CEO of Mid-State Cardiology in Nashville, Tenn.
    For example:
    A carrier may cite your practice for "poor quality of care" because you consistently report low-level codes. If you submit only 99231, the payer may interpret that as saying all hospital patients, regardless of their conditions, receive only a problem-focused history and exam. This can indicate to managed-care plans that your physicians never take a complete history and never perform comprehensive exams.

    2. Use MDM to Choose a Level

    Of the three E/M components - history, exam and medical decision-making (MDM) - you have to document only two to use one of the subsequent care codes, according to CPT.
    Most physicians find that they can best fulfill the documentation requirements with the exam and MDM components during subsequent hospital visits (because the admitting physician has already recorded the patient's history).
    If the cardiologist performs high-complexity MDM but only a problem-focused history and exam, you have problem-focused documentation. You would code this type of visit using 99231, regardless of the patient's case complexity.
    Remember: The patient's condition contributes to the MDM level. For example, a patient who develops an infection following a previous surgery may require moderately complex MDM (99232), but certain arrhythmias often require high-level MDM (99233).

    If the physician does not record the relevant information, however, the coder cannot support assigning a code for the care level that the doctor may feel he deserves, coding experts says. 
    "We audit our billings every quarter, and if we don't find the documentation to support the level charged, we ask our physician in charge of coding to meet with the physician who is documenting poorly to help him or her improve their coding," Lloyd says.

    3. Add Up Your Documentation

    Unfortunately, many cardiologists are unaware that virtually everything they do involving a patient can contribute to the documentation.
    For example, merely assessing a patient's general appearance counts as one element of the service's examination portion. When documenting subsequent hospital care, remember to include additional observations, coding experts say, such as:

  • Is the patient's condition stable?
  • Is the condition either improving or worsening?
  • Have any new problems developed?

    For instance, if a hospitalized diabetic patient's diagnosis includes high blood pressure, the doctor should document whether it worsens or improves. Documenting blood pressure and its resistance to change may support a higher-level code because of the greater MDM complexity required to manage it.
    You should also consider such factors as lab values and ultrasound and x-ray readings because you can use this information to support your MDM level. "I ask my cardiologist to cite labs or x-rays or whatever makes them state 'improving,' such as 'per blood urea nitrogen (BUN), patient is improving' or 'per EKG, patient is stable and not having any premature beats in the last 24 hours,' " says Colleen McKee, CPC, senior consultant and team leader with Knoxville Cardiovascular Group in Knoxville, Tenn.
    Most patients are sickest when first admitted, requiring a more complex diagnosis, examination and MDM - thus supporting a higher-level code. As the patient's condition improves, the level of subsequent visit coding will probably decrease because the physician  must no longer perform a detailed exam or more complex MDM.
    Coding can fluctuate, however, among the three levels during the course of a hospital stay. If, for example, a patient's condition worsens or if new problems or conditions arise during the hospital stay, the treating physician will likely perform more examinations and make potentially complex medical decisions. "Should the cardiologist code 99232, the patient's condition has to be worsening or the diagnosis has to change, so I ask them to clearly document the move up in E/M coding," McKee says. Therefore, doctors unfortunately can't live by any hard and fast rules for selecting low subsequent care levels.
    The challenge: Code 99231 involves "straight-forward or low-complexity decision-making," according to CPT. However, the problem is this code applies to any physician doing a follow-up visit. What is low complexity to a cardiologist may be high complexity to a family practice physician, Lloyd says. "The E/M visit is probably high complexity; it's just that the cardiologist's knowledge and experience make it 'routine' for her. Getting the cardiologist to think about it this way is a challenge!"

    4. Review the Charts to Identify Problems

    If your practice routinely reports the same code over and over, you should perform a chart review. Take a random chart sampling in which you reported 99231. On each file you should determine the history, exam and MDM levels and determine whether it meets the 99232 or 99233 requirements.
    "Last year, we looked at 99232, and based on those findings, we did some physician education," McKee says.

    If the physicians fail to see the importance of such a review, you want to try placing the number of visits they undercoded into a graphic format to show them how much money they left on the table.
    Because 99231 pays about $20 less than 99232, downcoding these claims just 10 times a month could cost your practice $2,400 per year.

  • Other Articles in this issue of

    Cardiology Coding Alert

    View All