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.
< The AMA website defines it a follows:
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
Here is another example that meets documentation requirements for a 99231:
Today marks my inaugural edition for my series of 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.With that said we will start the coding clinic series with CPT® code 99231.
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.
Some carriers in some states utilize the Trailblazer EM tool. There are a few key differences with Trailblazer vs Marshfield in how Medicare carriers are to interpret evaluation and management documentation. Here is a summary of those key differences. Here is the actual link to the Trailblazer E/M Audit reference pdf. If your carrier uses Trailblazer, this discussion may help you, but these additional resources should be reviewed as well for clarity.
The Lowest Level Hospital Follow-up Encounter( 99231
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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 MINIMIMUM 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 this card with me at all times and reference them all day long. It has prevented me from under billing thousands of times over the last decade.
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 this card with me at all times and reference them all day long. It has prevented me from under 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 notes . 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
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 for your 99231.
Here is another example of appropriate documentation for a 99231:
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 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 this table, because I'm just not smart enough to memorize it. I only use the table of risk when determining moderate and high risk and nothing else.
Here is another example that meets documentation requirements for a 99231:
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. 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 medical billing and coding dedicated to the little details of coding (including mid level hospital followups 99232 and 99233).
You can see much more in my free lectures on medical billing and coding dedicated to the little details of coding (including mid level hospital followups 99232 and 99233).
LINK TO E/M POCKET REFERENCE CARD POST
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Bravo!
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