Orthopedic Coding Alert

If your practice repeatedly reports 99231 for all of your subsequent hospital care services, this may not only cost your practice money: It could send a red flag to payers or mark you for an audit. According to CMS data, orthopedists report 99231 more often than any other subsequent hospital care code. This indicates that either most subsequent hospital visits are low-level services or orthopedists routinely undercode for inpatient care. As long as your documentation warrants it, however, you should feel confident in coding higher-level subsequent hospital care. Because carriers usually bundle hospital care into orthopedic surgeons' postsurgical visits, many orthopedists aren't familiar with the documentation guidelines associated with subsequent hospital care. If you pick up the patient's care after another physician such as a patient's primary-care physician admits the patient to the hospital, you should report the 99231-99233 code range. If your practice routinely reports 99231 for all of its subsequent hospital care services, tell your physicians that this might raise red flags with your payer. "This may not necessarily happen with Medicare, as there wouldn't be any program dollars for them to capture," says Jean Acevedo, LHRM, CPC, CHC, senior consultant at Acevedo Consulting Inc., a national coding and compliance consulting firm based in Delray Beach, Fla. "However, I recently audited a practice that an HMO flagged for 'poor quality of care'due to a consistent pattern of low-level codes.

"Think about what all 99231s might mean: All hospital patients, regardless of the patient's condition, only receive a problem-focused history and exam because that is what 99231 tells the payer you have provided," Acevedo says. "This can indicate to managed-care plans that your physicians never take a complete history and never perform comprehensive exams." Learn Coding Levels,Then Review Charts Most practices believe that documentation review is the first step to determine whether they can increase their inpatient coding levels, but that's actually the second step. If you don't know what constitutes each level of service, reviewing the documentation won't help you. So you should first educate your practice on what CMS requires for each level of care.

(See "Documentation Is Key to Selecting Accurate Codes" in article 4 for a list of CMS'documentation guidelines and orthopedic examples of the three subsequent hospital care codes.)

Acevedo offers the following basic guidelines for the three subsequent hospital care levels as a good starting point for physician education:
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. Choosing a Level Is a Hard Process Of the three E/M components history, exam and medical decision-making you must [...]