General Surgery Coding Alert
Don't Risk Losing Thousands on Subsequent Hospital Care
Strengthen documentation to improve your E/M claims Question 1: Did the Surgeon Specify Two of Three E/M Components? To avoid underreporting and underpayment for subsequent-care claims, make sure your surgeon's documentation assigns two of the key components to the following daily subsequent-care codes for a patient's evaluation and management. "The extent to which a physician performs history, exam, and MDM determines the level of service that is selected for a subsequent hospital care visit," Baker says. Question 2: Did the Surgeon Report Two to Seven Body Systems? For instance, the surgeon undertakes an unrelated subsequent hospital visit with an elderly patient admitted for hernia repair. The surgeon must examine and document at least two to seven body systems as part of a general multi-systems examination to report the visit using 99233. Question 3: How Can I Check Our 99231 Claims? If your surgery practice repeatedly reports the same subsequent hospital care code, you should perform a chart review to ensure you're accurately coding the visits, coding experts say.
Are you worried that your surgeon is downcoding subsequent-care claims, but you don't know what do? Use our experts' answers as a guide for documenting subsequent-care E/M components, body systems, and service levels.
The bottom line: Underdocumenting can result in undercoding, which in a year could cost the surgeon thousands of dollars.
For example, suppose your surgeon believes his documentation won't support a higher-level subsequent-care code, so he always uses 99231. Because 99231 pays about $20 less than 99232, downcoding these claims just 10 times in a month could cost your practice $2,400 per year, coding experts say.
Remember: The key components are the history, the exam and the medical decision-making (MDM), says Brett Baker, third-party payment specialist for the American College of Physicians in Washington, D.C.
For instance, the physician performs a subsequent-care visit on a recent appendectomy patient with a new complaint of left upper-quadrant stomach pain. She accurately documents an expanded problem-focused history and moderate-complexity medical decision-making. In this case you may be able to report 99232.
You would need to add modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) so the payer would know that the current E/M service was not related to the previous surgery.
Helpful tip: You should consider medical decision-making the most important E/M component to satisfy because it best supports medical necessity, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.
The body systems the surgeon may examine include:
"Take a random sampling of charts where you reported 99231, and on each file you should determine the history, exam and medical decision-making levels and determine whether they meet the requirements for a 99232 or 99233," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.
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