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E&M Inpatient audit

  1. Default E&M Inpatient audit
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    If someone happens upon this and could tell me what level you would code this I would be much appreciative. I have a provider who bills level 2 inpatient for new patient straight across the board. I am trying to train him. I would code this as 99221 but want a second opinion.
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    Quote Originally Posted by kpichon View Post
    If someone happens upon this and could tell me what level you would code this I would be much appreciative. I have a provider who bills level 2 inpatient for new patient straight across the board. I am trying to train him. I would code this as 99221 but want a second opinion.
    I would assess that as a 99232. The exam does not qualify as detailed because the affected area exam in no way qualifies as 'extended' so now you cannot bill any level of initial IP (and Observation) encounter and have to go with a subsequent IP encounter.

    Also, the ROS statement is poor...per the '95 DG's 'at least 10 systems must be reviewed. Those with positive or pertinent negative responses must be individually documented, For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented'.

    Your provider's statement does not meet any of these criteria. He needs some education I'm afraid.

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    thank you so much

  4. #4
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    Default E&M inpatient audit
    Quote Originally Posted by kpichon View Post
    thank you so much
    One thing to bear in mind though....different MACs have different criteria for what constitutes a detailed exam versus an EPF exam so I'd check yours out for clarification.

    All require some level of detail relating to the presenting problem, not just a couple of words. The criteria my client uses (but this is client-specific only) is that the OS/BA related to the presenting problem should contain at least half the bullets from the '97 DG's for that specific system. For example, the CV OS has 8 bullets so the provider would need four or more bullets for a CV-related problem along with other system related documentation to qualify as detailed.

    EPF vs detailed has always been contentious so at least my client has provided their own guidance. Do not use this for your own cases though....as I say this is client-specific only and this is a very large provider group (>1500 providers) so they need their own guidelines. It's really up to your manager to discuss this further....consistency is the name of the game in E/M.

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