Wiki Subsequent Inpatient Visits

[VSMichael]

I was recently informed by a fellow coder that in order to code for a level 3 subsequent hospital visit, there has to be no less than 4 diagnoses in the Provider's Assessment/Plan. This coder stated that if fewer than four diagnoses were listed in the Assessment/Plan part of the note, even if the MDM supported a level 3, then only a level 2 could be coded.
Does anyone know if this is correct? Thank you in advance!

 

[thomas7331]

There is no such rule that I ever seen or heard of - I would have to say that this is incorrect information. It may be an internal guideline specific to the practice where this coder works - some places come up with rules of thumb like this to try to prevent billing a higher level than is medically necessary, but this is not standard, and in my opinion would not be a correct coding practice. Each visit note must be evaluated on its own merits to determine the correct level.

 

[VSMichael]

There is no such rule that I ever seen or heard of - I would have to say that this is incorrect information. It may be an internal guideline specific to the practice where this coder works - some places come up with rules of thumb like this to try to prevent billing a higher level than is medically necessary, but this is not standard, and in my opinion would not be a correct coding practice. Each visit note must be evaluated on its own merits to determine the correct level.

I had never heard of that either. Thank you so much for your prompt reply!