Wiki Prematurity of Retinopathy babies

[KFLYNN70]

Does anyone have experience with Prematurity of Retinopathy. We do a lot of inpatient consults for this condition. We have providers who bill 99233 established inpatient for every patient whether they are worsening or stable. I am wondering how you would bill these? We are observing from week to week while they are inpatient for other conditions. My rule of thumb would be
1. Stable-no changes 99231
2. Worsening - 99232
3. Need of a Laser to save sight- 99233

Also, if the condition is not changing(ex: stage 1) and they are stage 1 the following week. is that considered worsening or is that stable?

 

[thomas7331]

Does anyone have experience with Prematurity of Retinopathy. We do a lot of inpatient consults for this condition. We have providers who bill 99233 established inpatient for every patient whether they are worsening or stable. I am wondering how you would bill these? We are observing from week to week while they are inpatient for other conditions. My rule of thumb would be
1. Stable-no changes 99231
2. Worsening - 99232
3. Need of a Laser to save sight- 99233

Also, if the condition is not changing(ex: stage 1) and they are stage 1 the following week. is that considered worsening or is that stable?

I don't have experience with the specific disease you are talking about here, but I can say that your E&M code choices have to be based on the documentation of each encounter, not coded based on the criteria you're listing here. The fact that a condition is stable or worsening is, as you say, a general 'rule of thumb' that can roughly determine medical necessity, but it is not a coding guideline - the code choice will need to be based on the history, exam and MDM (or time, if appropriate).

For an inpatient consult, you're normally dealing with a new problem for the initial visit, so a higher level code is to be expected, but if the subsequent visits involve a stable or improving problem, then your MDM will be lower and there won't be a need for as extensive history or exam, so naturally the level would also usually be lower. But again, each encounter note must be coded based on its own merits.

I'm not sure what you mean by an 'established' inpatient because inpatient care codes are never based on whether the provider has seen the patient previously or not. And if your providers are performing an inpatient consult, then you should be using the inpatient consult code range 99251-99255 (assuming that these are not Medicare patients and that the payer accepts these codes).

 

[KFLYNN70]

I am looking at subsequent visits for inpatient. 99231-99232-99233. The provider meets comprehensive on both HPI and Exam. The problem is the MDM. He has 2 dx codes Retinopathy of prematurity and Exotropia both are stable for these babies. The risk he is taking is observing to make sure the condition doesn't get worse and the baby doesn't go blind.

 

[thomas7331]

I am looking at subsequent visits for inpatient. 99231-99232-99233. The provider meets comprehensive on both HPI and Exam. The problem is the MDM. He has 2 dx codes Retinopathy of prematurity and Exotropia both are stable for these babies. The risk he is taking is observing to make sure the condition doesn't get worse and the baby doesn't go blind.

If the history and exam are comprehensive, then you have already met the requirements for 99233 regardless of MDM. Only two of three are required for subsequent visits.

Does your organization require that the level of MDM be met in order to code a particular level? If so, then the risk of blindness could quality for high risk, but to meet high MDM, the provider would also need to meet the high level in either the number of diagnoses or management options or the data reviewed category. If there was no change to the patient's condition and no new problem since the previous visit, then it's unlikely the first of the diagnoses category would be high (two stable problems per your description) but if the provider is reviewing extensive data, then it could still qualify as high MDM.

 

[KFLYNN70]

For inpatient- two out of the three, but one of two must be MDM. I agree with the last sentence you posted about the stable conditions.. ty

Subsequent Hospital Visits

Codes 99231-99233 can be used by any provider to report subsequent inpatient services.

Two out of 3 components of history, exam, and medical decision-making must meet or exceed the same level to assign a code (1 of the 2 has to be medical decision-making).

 

[rattyvonratkins]

I came across this thread when trying to research documentation tips for newborns with Retinopathy of Prematurity. The provider is wondering why I keep down-coding her IP visits and it's because I don't think her documentation meets History requirements for an initial exam, let alone initial L2 or L3. In particular, the HPI is troublesome. Can anyone share how they document comprehensive-level HPI for newborns with ROP?

This is a typical HPI example from one of this MD's chart notes. Is there any advice I can offer this provider on how to expand on HPI for newborns who have no discernable, outward ROP symptoms? Thank you in advance!

INFANT INFORMATION
Gestational Age: 25w2d
Current Age: 47 days
Birth Weight: 690 g (1 lb 8.3 oz)
Apgar 1 minute: 4
Apgar 5 minute: 5
Delivery Type: C-Section, Classical

HPI
Prematurity; at risk for Retinopathy of Prematurity based on gestational age and birth weight