Practice Management Alert

Why you'll report these codes a little differently than other E/Ms

When your physician provides subsequent hospital care to a patient, the onus is on you to choose the proper level of evaluation and management service based on the physician's notes.

But how can you decide which level of E/M service to choose? And how can you be sure your subsequent hospital care claims include the proper documentation? Experts say these are the two vital components of a successful claim.

Answer: Billers often under-report subsequent hospital care services, resulting in a lower payout and hurting the facility's overall finances. This could occur if a biller doesn't realize that she does not need to satisfy all three of the E/M components to report the subsequent care codes, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.

Another issue: You could also overcode subsequent care service if you fail to include documentation to back up your code choice. Overcoding subsequent hospital care visits could lead to denials and suspicious payers.

But don't just assume that subsequent hospital care coding is -mission impossible.- If you pay attention to the rules for billing these codes and observe the documentation guidelines, you can ethically max out your revenue for subsequent hospital care services.
 
2 out of 3 Ain't Bad for These E/M Codes

When you are choosing a level of service for these encounters, you-ll decide among three 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

- 99232--... an expanded problem-focused interval history; an expanded problem-focused examination; medical decision-making of moderate complexity

- 99233--... detailed interval history; a detailed examination; and medical decision-making of high complexity.

But be careful when selecting a code from this family because to claim 99231-99233, the physician only has to meet two of the three key E/M components, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

Example: The physician provides subsequent hospital care to a patient. The notes indicate that he performed an expanded problem-focused interval history with a problem-focused examination. MDM was of moderate complexity.

-You only need to have two out of three elements, so if the notes indicate a level-one exam, but indicate interval history is expanded problem-focused and MDM is of moderate complexity, then that's all you need,- Brink says.

On the claim, report 99232 for the service.

Another major hurdle when coding subsequent care claims is that everyone interprets the definitions for each level differently. -The problems that we run into with [coding] scenarios, including the clinical examples provided by the AMA in CPT 2006, is that not all doctors agree- about what constitutes level-one, -two and -three  subsequent hospital care services, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies  Inc. in Powder Springs, Ga. 

-Also, each [physician] documents differently, and regardless of the complaint or physician actions, it all comes down to the documentation and the medical necessity of the encounter,- she says.

If You-re Stuck, Start With Interval History

Billers having trouble deciding on a service level for 99231-99233 claims should start with the interval history, Brink says. If the physician is not documenting an interval history, make him aware of this problem, because an interval history can strengthen your subsequent care claim.

How? The interval history is the first step toward determining medical necessity, which is vital to proving a service level on subsequent care claims, Brink says.

-Even though the code set 99231-99233 only requires two out of three for history, exam, and MDM, interval history sets up the medical necessity for performing the type of exam and resulting MDM,- Brink says.

For example: The interval history states, -Patient's emphysema unchanged from yesterday, stable.- This would not necessitate a detailed or comprehensive exam or a high MDM, Brink says. -Probably a 99231 or 99232 level of service,- she says.
 
But suppose the interval history states, -End-stage emphysema has worsened since yesterday, breathing labored, in acute distress, pain level +8, hallucinating in and out; last admission indicates similar hallucination, CO2 gases greatly increased since yesterday.-

In this instance, the physician would perform a more detailed exam and more complex MDM (for example, since the patient's condition has deteriorated, the physician might change medication, order more lab tests, etc.). An encounter with this interval history--if properly documented-is likely a 99233 service.