Pulmonology Coding Alert

During the remainder of this year, the Health Care Financing Administration (HCFA) will be scrutinizing two evaluation and management (E/M) codes office or outpatient visit of an established patient (99214) and subsequent hospital care (99233) because a recent audit found these codes to be a common problem area.

In a letter to physicians last month, HCFA Administrator Nancy Ann Min-DeParle congratulated the medical community for its help in reducing the percentage of payment errors from 14 percent to 8 percent over the past four years. The letter, dated June 1, 2000, goes on to describe the results of a more careful look at HCFAs most recent audit of payment accuracy. In one area, HCFA found a number of common errors. We will ask Medicare claims-processing contractors, states DeParles letter, to focus educational and claims-review resources on these areas, and we urge you to take steps internally to prevent them. The full text of the letter is accessible via the Internet at http://www.hcfa.gov/medicare/mip/physltr.htm.

Regarding the codes themselves, the letter issues the following guidance: For physicians, we will be focusing this year on two CPT codes used to report E/M services 99214 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components [detailed history and examination/moderate complexity decision making]) and 99233 (subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components [detailed history and examination/high-complexity decision making]). These codes accounted for a significant portion of the coding errors in the last two audits. In fact, documentation for many of these services was found to be sufficient to support services that more appropriately are described by CPT codes 99212 (office or other outpatient visit...[focused history and examination/straightforward decision making]) and 99231 (subsequent hospital care...[problem focused history and examination/straightforward or low complexity decision making]).

The CPT code descriptors mention specific amounts of time typically required to perform the appropriate level of counseling and coordination of care activities. Time is one of the few guidelines established to help the physician determine which level of E/M to bill. For example, code 99233, the amount of time that a physician typically spends with a patient has been determined to be roughly 35 minutes at the bedside and on the patients hospital floor or unit (in comparison to 99231, which lists 15 minutes as typical). To use code 99233 appropriately, the documentation accompanying the claim must demonstrate that a comprehensive (general multi-system examination or a complete examination of a single organ system) took place. Code 99214 lists 25 minutes as typical (as compared to 10 minutes for 99212).

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