99231 CPT® Code Description, Progress Notes, RVU, Distribution.

This 99231 Current Procedural Terminology (CPT®) lecture reviews  the procedure code definition, progress note examples, RVU values and national distribution data.   This code is the lowest of the three Healthcare Common Procedure Coding System (HCPCS) inpatient hospital follow up codes.  The mid level CPT® 99232 and high level CPT® 99233 subsequent care codes are described elsewhere on The Happy Hospitalist as part of a complete collection of CPT® lectures written by myself.  I am an internal medicine physician with over ten years of clinical hospitalist experience in a community hospitalist program providing physician services for a large regional hospital system.  I have written a collection of  evaluation and management (E/M) lectures over the years to  help other physicians and other non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex and archaic world of hospital and clinic based coding requirements. While the lectures may be several years old, the information remains highly relevant. 

The original lectures and accompanying resources are used by myself to stay compliant with the rules and regulations of the  Centers for Medicare & Medicaid Services (CMS).  All my CPT® lectures have been organized in one easy-to-find resource on  Pinterest and can be accessed by clicking here.   You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures.  As you're learning to understand CPT® E/M codes, remember that you have an obligation to make sure documentation supports your level of service you are submitting for payment.    The volume of your documentation should not be used to determine your level of service. It is the details of your documentation that matter most. In addition, the E/M services guide says the care you provide must be  "reasonable and necessary".  In addition, all entries should be dated and contain a legible signature or signature attestation, if necessary.   

99231 CODE DESCRIPTION


My interpretations detailed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making.  These resources can be found in my hospitalist resources section.       The Marshfield Clinic point system  is voluntary for Medicare carriers but has become the standard compliance audit tool in many  parts of the country.  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 in my free educational discussion.  I recommend all readers obtain their own up-to-date CPT® reference book as the definitive authority on CPT® coding.  I have provided access to Amazon through the  2015 CPT® standard edition pictured below and to the right.  CPT® 99231 is a hospital billing code and can be used by any qualified healthcare practitioner to get paid for their inpatient hospital subsequent care evaluations.  The American Medical Association (AMA) describes the 99231 CPT® procedure code as 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.
This code can be billed based on time under certain circumstances.  I have detailed those discussions elsewhere.  Documentation of time is not a required component to stay in compliance with CMS regulations.  If billed without time as a consideration, CPT® 99231  compliance is based on documentation detailed in the 1995 or 1997 guidelines referenced above.  The three relevant components to a hospital follow up note are the:
  1. History 
  2. Physical Examination
  3. Medical Decision Making Complexity  
For all hospital follow up billing codes (99231, 99232, 99233),  the highest documented two out of three above components determines the correct code.  Compare this with the highest documented three out of three above components being required for hospital initial patient care encounters.  Again, only the highest two out of three components are needed to determine the correct level of care.  The following discussion details the absolute minimum requirements required to remain in compliance with CPT® 99231.   In addition,  a face-to-face encounter is always required to stay in compliance.  
  • Problem focused interval history:   Requires only 1-3 components for the history of present illness (HPI) OR documentation of the status of THREE chronic medical conditions.  No past medical history or social history or family history or review of systems is required.  Note,  just one component of the HPI is required.
  • Problem focused physical exam:  Requires requires 1-5 organ systems (1997 guidelines).  Three vital signs are considered one organ system.  Therefore, documentation of just three vital signs meet criteria for a  low level hospital follow up billing code. The CMS E&M guide on pages 31 and 32 describes the acceptable body areas and organ systems on physical exam. 
  • Straight forward or low complexity medical decision making (MDM):  This is split into three components.  The 2 out of the 3 highest levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk.  What are the three components of MDM and the minimum required level of points and risk as defined by the Marshfield Clinic audit tool?
    • Diagnosis (1 point)
    • Data (0 points)
    • Risk (minimal)  
The medical decision making point system is highly complex.  I never use the risk table (found on page 37 here) on MDM for a low level hospital follow up note.  It is not necessary to meet documentation requirements.  I have a detailed reference to it  on my E/M pocket cards described below.     These cards help me understand what type of care my documentation supports.   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.

CLINICAL EXAMPLES OF 99231


What are some documentation examples for a CPT® 99231, the level 1 hospital follow up progress note?  Most doctors use the subject, objective, assessment and plan (SOAP) note format.  A 99231 note could  look like this:
S)  No pain (1 HPI)
O) 120/80   80    Tmax 98.9 (three vital signs = one organ system)
A) Nothing needed
P)  Nothing needed
In this example  history (subjective) and physical (objective) meet the requirements to get paid for a 99231.  Remember, the highest  2 out of 3 components determine the highest level of service for hospital subsequent care visits.  Do note that linking an ICD code to a CPT® code is required for all visits submitted for reimbursement from CMS.  Therefore, most progress notes should provide at least one ICD code  to clearly indicate a purpose for the visit.  I suspect this is necessary  to meet the reasonable and necessary threshold, unless that can be inferred from other chart documentation.  Medicare doesn't want to pay for doctors to talk about basketball with their patients.  There must always be an approved ICD code linked with the CPT® code when billed to CMS.

I think it's always a good habit to include at least on ICD code, even though it's not technically required for hospital follow up visits that can achieve compliance with history and physical components alone.  Remember, the highest supported level of documentation for 2 out of 3  from  history, physical and medical decision making on hospital follow up visits determine the appropriate level of service.    For history, just one component of the HPI  (character, onset, location, duration,  what makes it better or worse etc.) or  documentation of  the status of three chronic medical conditions is required for this level one progress note.  For physical exam, documentation of only one organ system is required and three vitals counts as one organ system.   Here is another clinical example of a SOAP note for a CPT® 99231 hospital subsequent care visit:  
S)Nothing
O) 120/80 80 Tm 98.6 (three vital signs = one organ system)
A)HTN-stable, no changes planned.
    DM-stable, no changes planned.     (the status of three chronic medical conditions in place of HPI)
    COPD-stable, no changes planned.  
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 for physical exam if nothing else is relevant and your documentation is complete and accurate in order to get paid for a 99231.  Note also, this documentation can support a CPT® 99231 code with no reference to proof of a face-to-face encounter.  One could document vital signs from home and never see the patient and meet the criteria for a CPT® 99231.   Medicare, however,  only pays for face-to-face encounters on E/M visits.  I do not recommend billing for CPT® 99231 without a face-to-face encounter.   Medicare may kindly ask for their money back.    Here is another clinical example of appropriate documentation for a CPT® 99231:
S)  Nothing needed
O) 120/80 80 Tmax 98.6  (three vital signs = one organ system)
A) 1) HTN, controlled (one point for diagnosis)
P)  Nothing needed
According to 1995 or 1997 guidelines, I can document a level one CPT® 99231 without ever asking the patient a question or laying hands on them, although a face-to-face evaluation is always 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, reasonable and necessary is always  part of any evaluation.

There is a complicated  table of risk  that represents the last component of the decision making complexity and detailed on the CMS E&M guide linked through my hospitalist resource center from above.  What I have on my quick reference E/M coding card below only represents examples of moderate and high risk  because one can achieve the 99231 quite easily with minimal history and physical documentation requirements.   I never use the risk table for a low level hospital follow up progress note because I'm just not smart enough to memorize it.  I only use the table of risk when determining moderate and high risk encounters.  Here is another clinical example that meets documentation requirements  for a CPT® 99231:
S)No Pain (one HPI)
O)Nothing
A)HTN, no change (one point for diagnosis)
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 medical decision making (HTN-stable).

Detailed above is the bare minimum required for a low level subsequent care visit in the hospital.   This is not my patient population.  That's why my total yearly level one documentation with CPT® 99231 is pretty low.   Most patients in the hospital these days are much more complex than a level one hospital follow up progress note. Most hospital patients require an intensity of service much higher than a daily 99231.  If a physician is billing a daily CPT® 99231,  the patient should probably be at home watching Oprah  or out golfing.

DISTRIBUTION OF SUBSEQUENT CARE CODES


What is the distribution of CPT® 99231, 99232 and 99233 for internal medicine in the country?  One Medicare contract carrier actually told us the answer in a January, 2013 pdf presentation (based on January 2011 through December 2011 data).  This data represents internal medicine and not the hospitalist subspecialty within internal medicine. 
  • 99231:  about 8% of total inpatient subsequent care codes. 
  • 99232:  about 62% of total inpatient subsequent care codes.
  • 99233:  about 30% of total inpatient subsequent care codes.  

One additional resource described the ten year trend (2001-2010) of E/M coding trends.   The OIG published a report  in May, 2012 titled Coding Trends of Medicare Evaluation and Management Services.  As you can see, the proportion of 99231 vs 99232 vs 99223 has shifted to higher intensity of service codes over the last 10 years.  This data is for all Medicare E/M charges in this code group and not limited to internal medicine as reviewed just above.  As you can see, in 2010, 25% of subsequent inpatient hospital care codes were 99233, 59% were 99232 and 15% were 99231.

Subsequent-Inpatient-Hospital-Care-Codes-10-Year-E/M-Trend-OIG-Table

Inpatient-Hospital-Subsequent-Care-10-Year-Graph-2001-2010

Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99231 encounters were billed and the dollar value of their services for Part B Medicare.    As you can see in the image below, E/M code 99231 had 12,406,607 allowed services in 2011 with allowed charges of $476,566,436.37 and payments of $377,167,207.65.

99231-99233 National Procedure Summary File CMS 2011

RVU VALUE


How much money does a CPT ® 99231 pay in 2014?  That depends on what part of the country you live in and what insurance company you are billing.    E/M codes, like all CPT® codes are paid in RVUs.  This complex discussion has been had elsewhere on The Happy Hospitalist.  For raw RVU values, a CPT® 99231 is worth 1.10 total RVUs.  The work RVUs are 0.76.  A complete list of RVU values on common hospitalist E/M codes can be found here.  What is the 99231 Medicare reimbursement?  In my state, a CPT® 99231 pays about $37 in 2014. The RVU to dollar conversation rate in 2014 is 35.8228.

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 many more of my  E/M lectures here


LINK TO HOSPITALIST E/M REFERENCE CARD POST


EM Pocket Reference Cards Using Marshfield Clinic Point Audit



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