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Orthopedic Coding Alert

Subsequent Hospital Care:

Documentation Is Key to Selecting Accurate Codes

Published on Tue Apr 01, 2003

Once your practice learns CMS'requirements for documenting subsequent hospital care, you can more accurately assign codes from the 99231-99233 series. Here are CMS'documentation guidelines for these codes:

  • 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity.

    Service should be approximately 15 minutes in length and should entail medical decision-making for limited diagnosis and management options posing low risk. The history of present illness (HPI) should review one to three components. The examination should be limited to the affected body area or organ system.

  • 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity.

    Service should take approximately 25 minutes and entail medical decision-making for multiple diagnosis and management options or a new problem posing moderate risk. HPI should include one to three components and a review of systems (ROS) of one system. Examination is limited to the affected body area or organ system and other symptomatic or related organ system(s).

  • 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history; a detailed examination; medical decision making of high complexity.

    Service should be approximately 35 minutes long and entail medical decision-making of high complexity, meaning that it involves extensive diagnosis and treatment options, posing high risk. HPI should review four or more components with a review of symptoms in two to nine organ systems. Examination extends to the affected body area(s) and other symptomatic or related organ system(s).

    Note: These examples follow CMS'1995 documentation guidelines, which most orthopedists favor.

     

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