You will learn in detail how to bill CPT code 99231. As anyone who reads my blog knows, I consider myself well in tune with the ridiculous coding rules established by the Medicare National Bank. In the past, I have posted extensively on coding and documentation. We document to get paid. We document so we don't get sued. We document so the government can track if we've been good or bad. We document so the hospital gets paid more. We document to make our mortality data look better. We document so the government has lots of data to pay lots and lots of people to extrapolate the data. In last place, we document to remember the reasons for the encounter with our patient. Now, what we write and how much we write is all driven by third party rules. I described it well in some of my classic works of art below....
You can see much more here in my coding lectures or earn CME at E&M University.
Today marks my inaugural edition for my series of coding clinics. Remember, nothing I say here means Jack. I am not a licensed coding compliance officer. I am a physician with a very good understanding of the rules. What I say doesn't matter since I'm not the one paying your bills. The Medicare National Bank owns your paycheck, so you have to do what they say. It doesn't matter if I'm right or not. My interpretations are based on my understanding of the Evaluation and Management Guidelines of 1995 and 1997. As of November 2005, until further notice, carriers have been directed to use these guidelines in their reviews. If you disagree with my statements, you will be tarred and feathered. With that said We will start the coding clinic series with CPT code 99231
The Lowest Level Hospital Follow-up Encounter (99231)
The AMA website defines it a follows:
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.
15 minutes? Riiiiiigggghhhtttt..... This lowest level code, in my state, would pay just over $30 from the Medicare National Bank. How much is that an hour? About $120 an hour. My lawyer charges double that. It's insulting to say the least. But I don't make the rules. I only follow them. These codes don't bill based on time, They pay based on documentation of based on the 1995 or 1997 guidelines I listed above.
You can see much more here in my coding lectures or earn CME at E&M University.
As you know, there are three components to a hospital follow up note
Now, in all hospital follow up codes (99231, 99232, 99233), the HIGHEST DOCUMENTED TWO OUT OF THREE COMPONENTS WINS THE CODING GAME. You only need the highest two out of three for hospital follow up visits.
The following are the ABSOLUTE MINIMAL REQUIREMENTS, as expressed by the established guidelines, to get paid for a 99231, or $30.
- History requires only ONE component of HPI OR the status of THREE chronic medical conditions.
- Physical only requires ONE organ system (three vital signs constitute one organ system)
- Decision making complexity is split into three components. You need 2 out of the 3 highest levels to determine the overall level of decision making. These three components are 1) Diagnosis (ONE POINT) 2) Data (ZERO POINTS) 3) Risk (MINIMAL)
The points system for the decision making complexity is highly complex and is listed below on my yellow card I developed and for which I carry with me and refer to often on my rounds. The maximum points allowed for diagnosis and data sections is 4 points. This represents the highest level of decision making for that category.
click to enlarge
So what does the lowest level documentation look like for a level one 99231 hospital follow up visit that pays just over $30? Doctors use S.O.A.P. notes. Subjective. Objective. Assessment. Plan notes (at least before EMRs destroyed that). It is doctor lingo carried on for decades. The language all doctors understand when looking at a patient's chart.
A 99231 note can look like this:
S) No pain
O) 120/80 80 Tmax 98.9 (three vital signs)
A)Nothing needed
P) Nothing needed
In this example History (subjective) and Physical (objective) meet the requirements to get paid for a 99231. You need nothing else. Remember, you only need 2 of 3 areas: history and physical, or history and decision making, or physical and decision making. For history, you need just one component of the HPI (character, onset, location, duration, what makes it better or worse...) or document the status of three chronic medical conditions. For physical, you only need one organ system, and documenting three vitals counts as one organ system. You don't need to document anything else to get paid appropriately for a 99231
You can see much more here in my coding lectures or earn CME at E&M University.
As another example:
S)Nothing
O) 120/80 80 Tm 98.6
A)HTN-stable
DM-stable
COPD-stable
P) Nothing
As you know, documenting the status of three chronic medical conditions can be substituted for the HPI. With that said, you only need to document three vitals and your documentation is complete and accurate to get paid your $30 for you 99231.
Here is another example of appropriate documentation to fend off the fraud police:
S) Nothing needed
O) 120/80 80 Tmax 98.6
A) 1) HTN, controlled
P) Nothing needed
According to 1995 or 1997 guidelines, I can document a level one 99231 without ever asking the patient a question or laying hands on them. According to the guidelines, documenting the status of one chronic medical condition qualifies as low level risk in the decision making process. I have meet my requirements for 2 out of 3 areas by meeting requirements for physical exam (documenting three vital signs) and the decision making component (by documenting the status of one chronic medical condition)
There is a very complicated TABLE OF RISK that represents the last component of the decision making complexity. What I have on my yellow card above represents only the high risk table, as I only use the high risk table to achieve a high level 99233. But for the sake of teaching one can see all the different levels of risk that we are expected to memorize to achieve the right documentation at the right time, every time. I NEVER use this table, because I'm just not smart enough to memorize it. I only use the table of risk when determining high risk, and nothing else.
Here is another example that meets documentation requirements for a 99231 for the chart police:
S)No Pain
O)Nothing
A)HTN, no change
P)Nothing
That's all you need folks. Documentation of 2 out of 3 areas at the lowest level needed. That means one HPI (no pain) and one Physical exam (three vital signs) , OR one HPI (no pain) and low complex medical decision making (documentation of one stable medical problem such as HTN-stable), OR documentation of Physical exam (three vital signs) and low level decision making (HTN-stable).
That's it. Nothing more, nothing less. This is not my patient population. And that's why my total yearly level one documentation 99231 can be counted on one hand out of 2500 or more encounters. I guess I shift the bell curve to the right. And appropriately so. If you are billing a level one, you should not be billing at all. The patient should be at home watching Oprah or out golfing. If you are billing excessive numbers of level ones, you are shifting the bell curve of all your doctor colleagues to the left and inappropriately raising red flags for everyone who is doing it correctly. Shame on you for screwing yourself and every doc around you. Now stop it.
1 Outbursts:
Bravo!
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