Coding Clinic 99232

My first coding clinic was the 99231, better known as the wave from the door code as you walk by the room.  Next up is the 99232, the mid level hospital follow up code. Where you actually have to at least look at the patient to qualify.   Before we begin,  the lawyer garbage is being regurgitated here:

Before we begin read my Happy Lawyer statement in my side bar.  If you still don't understand it,  let me say it in easier terms.  

Nothing I say here means Jack.  I am not a licensed  coding compliance officer.  Even if I was,  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.  

How does the AMA define a 99232?

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate 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 responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.

25 minutes?  Really.  In my state a 99232 pays $6o.  That works out to $144 an hour if in fact a 99232 really took 25 minutes.  A colonoscopy without specimen collection (45378), pays about $180 if it's done at the hospital,  $330, if it's done at the docs office.  If you do a single biopsy (45380), it pays $220, if done at the hospital, $400 if it's done at the docs office. I'm pretty certain after several thousand of 'em, I could do at least two an hour, maybe three.   This also explains why every colonoscopy has a random biopsy.  You would be throwing away $80 an hour not to do it.  You do the math.  $144 an hour for cognitive care, or $800 an hour or more for screening colonoscopies at the office.  

Regardless, lets' focus on the 99232.  Here is my card again.  The card I carry with me at all times,  to determine the correct level of coding.  The card tells me the absolute minimum I need to document to achieve a level 2 hospital follow up visit. Click on the image to enlarge

If you need more understanding, see my first coding clinic for a more thorough explanation.  You need the highest 2 out of 3 documented levels from history, physical and decision making.  

Below is the  absolute bare minimum you need to document in each level to achieve an appropriate 99232 payment.  But remember, you only need to get two out of three for hospital follow up visits:  history and physical, history and decision making,  or physical and decision making.  So here it is, the absolute bare minimum you must write.

History

1)  One HPI (Character, onset, location, duration...) OR the status of three chronic medical conditions

AND

2)  One ROS

Physical

2 organ systems.   The 1995 guidelines state up to 7 systems or limited exam of affected body area and other symptomatic or related systems.  Documenting three vital signs is considered one organ system

Decision Making  You need two out of the following three to be considered 99232 material

1) Diagnosis:  3 points (look on my yellow card)

2) Data:  3 points (look on my yellow card) 

3) Risk:  Moderate.  The picture below is the risk table.  You need to look it up to see if moderate risk is achieved:

                                                                 Click image to enlarge

Now,  I NEVER use this risk table for anything other than high risk/99233 billing because I'm just not smart enough to remember it all.  And I can't fit it on my card.  I don't need it anyway  Since you only need 2 out of 3 components,  based on the coding guidelines I can achieve a 99232 in almost every patient through correct documentation of history and physical components.  Remember, 2 out of 3.

So what would a level two 99232 hospital follow up note look like that met all coding guidelines?  In classic S.O.A.P. note form this is all you need:

S)  sharp pain in abd (HPI),  no SOB (ROS)

O) 120/80  70  Tm 98.6 (three vitals is one organ)

     Alert

A)  Nothing needed

P)  Nothing needed.

OR,  if you want to document the status of three chronic medical conditions to substitute for your HPI you can write the following

S) No SOB

O) 120/80 70 Tm 98.6

      Alert

A)  HTN, stable

      COPD, stable

      CAD, stable

P)  Nothing needed.

That's all you need folks.  I rarely ever rely on the decision making component to get me a level 2 (99232) because I can't  spend 5 minutes on every patient adding up points and I sure as hell will never ever use the risk table for a 99232.  It's just plan stupid.  I can achieve a 99232 much easier through documentation of history and physical components.  And remember, once again, you only need two out of three.

I didn't make the rules.  I just follow them.  

The sad thing is,  if you look at my first SOAP note example,  and I was a doc who knew nothing about the patient, and I showed up to read the chart, I would get almost no meaningful information from this pile of crap.  But this pile of crap is all structured around people looking at the following four pages below and cross referencing it with my note, to make sure I'm not a fraudster.  Just think how many  layers of excess waste is  built in to justify the existence of rules that really have no patient benefit.  If anything,  it encourages notes that are clinically irrelevant and lack substance.  

But that's the rules.  

                                                     Click all of them to enlarge (you won't be disappointed)