You will learn in detail how to do medical coding for 99231. As anyone who reads my blog knows, I consider myself well educated in the rules and requirements of evaluation and management (E&M) coding. Today marks my inaugural edition for my series of free educational coding clinics. Before I begin, here is my disclaimer:
I am not a licensed coding compliance officer. I am a hospitalist physician with years of experience studying this stuff. Read at your own risk. My interpretations here are based on my review of the 1995 and 1997 guidelines and the CMS E/M guide along with the Marshfield Clinic point system for medical decision making (see my hospitalist resources for reference to these sites). The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard in most parts of the country. However, you should check with your own Medicare carrier in your state to verify whether or not they use a different standard than that for which I have presented here on my free educational discussion.
With that said we will start the coding clinic series with CPT® code 99231. The AMA defines 99231 as below. Reference the 2013 CPT at Amazon as the definitive authority on CPT® coding.
I am not a licensed coding compliance officer. I am a hospitalist physician with years of experience studying this stuff. Read at your own risk. My interpretations here are based on my review of the 1995 and 1997 guidelines and the CMS E/M guide along with the Marshfield Clinic point system for medical decision making (see my hospitalist resources for reference to these sites). The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard in most parts of the country. However, you should check with your own Medicare carrier in your state to verify whether or not they use a different standard than that for which I have presented here on my free educational discussion.
With that said we will start the coding clinic series with CPT® code 99231. The AMA defines 99231 as below. Reference the 2013 CPT at Amazon as the definitive authority on CPT® coding.
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.
These codes don't bill based on time, They pay based on documentation of based on the 1995 or 1997 guidelines I listed above. As you know, there are three components to a hospital follow up note
- History
- Physical Examination
- Decision Making Complexity
Now, in all hospital follow up codes (99231, 99232, 99233), the highest documented two out of three components determines the correct code. You only need the highest two out of three for hospital follow up visits.
The following are the absolute minimum requirements as expressed by the established guidelines, to get paid for a 99231.
- History requires only ONE component of HPI OR the status of THREE chronic medical conditions.
- Physical only requires ONE organ system (three vital signs are considered 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 medical decision points system is highly complex. It is one aspect I have included on my E/M pocket reference card based on my interpretations of the 1995 and 1997 CMS guidelines I carry with me all day long. I have developed bedside E/M reference cards (see below) to help me understand what type of care my documentation supports, based on CMS guidelines. I carry these cards with me at all times and reference them all day long. They have prevented me from under and over billing thousands of times over the last decade.
So what does the lowest level documentation look like for a level one 99231 hospital follow up visit? Doctors use S.O.A.P. notes. Subjective. Objective. Assessment. Plan. 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:
A 99231 note can look like this:
S) No painO) 120/80 80 Tmax 98.9 (three vital signs)A)Nothing neededP) Nothing needed
As another example:
S)NothingO) 120/80 80 Tm 98.6A)HTN-stableDM-stableCOPD-stableP) 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 for your 99231.
Here is another example of appropriate documentation for a 99231:
S) Nothing neededO) 120/80 80 Tmax 98.6A) 1) HTN, controlledP) 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, although a face-to-face evaluation is required. 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). Remember medical necessity is part of any evaluation.
There is a very complicated table of risk that represents the last component of the decision making complexity. What I have on quick reference coding card above represents only moderate and high risk table because one can achieve the 99231 quite easily with minimal history and physical documentation requirements. 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 the risk table for a 99231 because I'm just not smart enough to memorize it. I only use the table of risk when determining moderate and high risk.
Here is another example that meets documentation requirements for a 99231:
S)No PainO)NothingA)HTN, no changeP)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. Most hospital patients require an intensity of service much higher than a daily 99231. The patient should be at home watching Oprah or out golfing on 99231 evaluations. 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. Now stop it. My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see much more in my free lectures on hospital E/M coding dedicated to the little details of coding.
LINK TO HOSPITALIST E/M REFERENCE CARD POST
|
Bravo!
ReplyDelete