99232 CPT® Code Description, Progress Notes, RVU, Distribution.

This 99232 Current Procedural Terminology (CPT®) lecture reviews  the procedure code definition, progress note examples, RVU values and national distribution data.  CPT® 99232 is the middle of the three Healthcare Common Procedure Coding System (HCPCS) inpatient hospital follow up codes.  The low level CPT® 99231 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.   In addition, I have written a side-by-side comparison lecture detailing coding elements of 99232 vs 99233.  I am a board certified internist with over ten years of clinical experience in a community hospitalist program providing physician services for a large regional hospital system. I have written an extensive collection of evaluation and management (E/M) lectures over the years to help other physicians and other non-physician practitioners (nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives) understand the complex  world of hospital and clinic based E/M coding requirements. These lectures may be several years old, but the information remains highly relevant today.

These 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 are organized in one easy-to-find resource on Pinterest.   You don't need to be a Pinterest member to get view any of my CPT® procedure lectures. As you are learning to understand CPT® E/M codes, always remember that you have an obligation to make sure documentation supports your level of service you are submitting for reimbursement. How much you write on the chart  should not be used to determine your level of service. What matters are the required details of your documentation according to the rules discussed in this and other CPT®  lectures. The E/M services guide says the care you provide must be "reasonable and necessary".  In addition, all progress notes must be dated and have a legible signature or proof of signature attestation. 

99232 CODE DISCUSSION 

 

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.  Make sure to 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 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. The 2014 CPT® standard edition pictured below and to the right can by found as a click through Amazon resource for purchase. CPT® 99232 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 99232 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: 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 resp onding 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. 
This code can be billed based on time under certain circumstances. I have detailed those discussions at the link provided. However, documentation of time is not a required component to stay in compliance with CMS regulations. If this code is billed without time as a consideration, CPT® 99232 compliance should be based on documentation requirements detailed in the 1995 or 1997 guidelines referenced above in my hospitalist resource section. The three relevant components to a hospital follow up note are the:
  1. History
  2. Physical Exam
  3. Medical Decision Making Complexity (MDM)
For all inpatient hospital subsequent care progress notes (99231, 99232, 99233), the highest documented two out of three levels for history, physical and  MDM will determine the correct level of service. Compare this with the requirement for the highest three out of three on initial hospital care encounters. Again, only the highest two out of three components are needed to determine the correct level of care for follow up hospital notes. The following discussion explains the absolute minimum requirements required to remain in compliance with CPT® 99232. In addition, always remember that a face-to-face encounter is required when submitting documentation to CMS for reimbursement.
  • Expanded problem focused interval history: Requires 1-3 components for the history of present illness (HPI) OR documentation of the status of 3 chronic medical conditions AND 1 review of systems (ROS).  No past medical history or family history or social history is required (PMFSH).   
  • Expanded problem focused physical exam
    • 1995 E/M guidelines require up to 7 systems or limited exam of affected body area and other symptomatic or related systems. Note the wordage difference with body systems or areas.  They are not the same. The guidelines don't really clarify what "up to 7 systems" means so it's hard to justify exactly what that means. By this definition, just one system would qualify.  I recommend instead to consider using the clearer 1997 guidelines.  
    • 1997 E/M guidelines require at least 6 bullets from one or more organ systems.  A review of the acceptable "body areas"  and "organ systems"  can be found in the CMS E&M reference  guide on pages 31 and 32
  • Moderate complexity medical decision making (MDM): This is split into three components. The 2 out of 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 (3 points) 
    • Data (3 points) 
    • Risk (moderate) The table of risk can be found on page 37 of the CMS E&M reference guide.
The medical decision making point system is highly complex. 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 over or under billing everyday over the last decade.

CLINICAL EXAMPLES OF 99232


What are some clinical examples for a CPT® 99232, the level 2 hospital follow up progress note? Most doctors use the subject, objective, assessment and plan (SOAP) note format. A 99232 note could look like this:
S)  sharp pain in abd (1 HPI),  no SOB (1 ROS)
O) 120/80  70  Tm 98.6 (three vitals is one organ)
Alert, abdomen soft, bowel tones present, regular pulse, no wheezing, no leg edema, no rash (at least 6 bullets from at least one organ system)
A)  Nothing needed
P)  Nothing needed.
In this example,  CPT® 99232 requirements are met through the history and physical components.  Remember, for subsequent care visits, the highest 2 out of 3 for history, physical and MDM determines the overall level of service.  In this case, 1 HPI and at least 6 bullets makes this a level 2 progress note.  Always remember, however, that all insurance companies require CPT® codes to be linked to at least one ICD code.  If no ICD code is linked, you may fail an audit, unless the ICD code can be inferred elsewhere in the chart (such as the orders).  I always recommend documenting at least one assessment problem for a CPT code to be linked to for payment.   The problem is the ICD code.  ICD stands for International Classification of Diseases.  Here is another clinical example of a 99232 based on history and physical:
S) No SOB (1 ROS)
O) 120/80 70 Tm 98.6
Alert, reg pulse, no wheezing, no leg edema, no rash (at least 6 bullets from 1 organ system)
A)  HTN, stable, no changes planned
COPD, stable, no changes planned  (status of 3 chronic medical conditions in place of HPI)
CAD, stable, no changes planned
P)  Nothing needed.
This is a level 2 progress note based on history and physical.  The status of 3 chronic medical conditions substitutes for the HPI and meets the minimum requirement of 1 HPI.  Add in 1 ROS and this is a level 2 history.  The physical exam has at least 6 bullets from 1 organ system so this is a level 2 physical exam for hospital follow up. Note, while I have written the problems in my assessment, I am applying them to my HPI.  CMS does not require SOAP notes.  This is just how physicians are taught.  I could write my note in essay form if I chose to do so.  Sometimes, I apply the status of my 3 chronic conditions to apply to my data points too in MDM.  They should apply because the documentation supports it.  Here is another 99232 progress note based on history and MDM:
S)  ROS not able secondary to delirium. (highest level ROS by default). HPI patient has delirium since last night.(1 HPI)
O) 120/80  70  Tm 98.6 (one bullet)
A)  Left arm swelling consistent with cellulitis, new onset ( 3 points, new problem no workup)
P)  Start antibiotics. (moderate risk for prescription drug management)
In this example, the history meets the highest level of care based on the inability to obtain a history. This is a level 3 history.  The physical exam, however, only meets criteria for a level one follow up visit because it only has one bullet (three vital signs).  The MDM is moderate because it  meets a level two for diagnosis based on the 3 points for a new problem with no workup planned.  In addition, the risk table gives this moderate risk because of prescription drug management.  Because this note has a level one physical, a level 2 MDM and a level 3 history, the highest two out of three places this note into a level two progress note.  See how easy that is?  This is why my E/M bedside reference cards detailed below are so valuable.  We  do things every day that we under appreciate and under bill as a result.  Remember, volume of the note does not matter.  What's documented determines the level of service.  Here's one final clinical example to review:
S) No CP (1 ROS)
O) Nothing
Hgb, 12.4 (1 point)  ECG tracing personally reviewed shows chronic afib (2 points)
A) CAD, stable, no changes planned (1 point)
     COPD, stable, no changes planned (1 point)  (status of 3 chronic medical conditions)
     Chronic Afib,  stable, no changes planned (1 point)
P)  No changes
This note meets a level 2 subsequent care progress note based on history and MDM.  The status of three chronic medical conditions meets the criteria for a full HPI, more than enough for the required 1 HPI.  With 1 ROS, this is a level 2 history.  The physical offers nothing in this example.  The MDM is moderate because it gets 3 points under the diagnosis component for describing established problems, stable or improved.  The data portion gets three points, one point for reviewing lab and two points for personally reviewing the ECG.  The risk table does not apply here.  Remember, MDM is determined by the highest two out of three for diagnosis, data and risk.

I hope these common clinical examples offer further proof that documentation is key to staying compliant.  Writing a novel is not required. As physicians, I think we tend to underestimate the level of complexity we encounter because we are used to it.  We need to do a better job of documenting what we do and understand the rules we have been given to follow.  Notice these notes are not long essays.  They are strategically written to capture value in work we are doing but not describing in the correct manner.  Don't be afraid to bill 99232 if the face-to-face encounter you provide is medically reasonable and necessary and your documentation supports CPT® 99232.

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).  I do not believe this data reflects the subspecialty of hospitalist medicine within internal medicine as a whole.
  • 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® 99223 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 99232 had 50,949,134 allowed services in 2011 with allowed charges of $3,572,992,374.69 and payments of $2,835,426,378.50.
99231-99233 National Procedure Summary File CMS 2011

   

RVU VALUE

 

How much money does a CPT ® 99232 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® 99232 is worth 2.02 total RVUs. The work RVUs are 1.39. A complete list of RVU values on common hospitalist E/M codes can be found at this linked resource. What is the 99232 Medicare reimbursement? In my state, a CPT® 99232 pays about $69 in 2014. That's about $30 more than a 99231.  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. Make sure to review all my other  E/M coding lectures too.


LINK TO BEDSIDE E/M CODING CARD POST


EM Pocket Reference Cards Using Marshfield Clinic Point Audit



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5 Outbursts:

  1. Genius! Especially the part about notes being structured around convincing the auditors you're not defrauding the MNB, rather than documenting something important about the patient's care. I can't remember the last time I bothered reading a patient's chart to learn what was going on in the case. There's nothing in there anymore that is useful for clinical care. Just for billing. So I hunt down another doc, get my information that way, and let them know what I think by word of mouth, too. Charts USED to be used to facilitate communication among the docs taking care of the patient. Now their only function is to satisfy compliance officers. What a waste.

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  2. Linked to this post via JunkFood Science; as a patient with a lot of experience dealing with a variety of doctors, you've convinced me yet again: I need to maintain my own healthcare chart if I want to keep track of who has done what and what the results were.

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  3. You know what -- this blog reads like a physician who doesn't care anything about the patient and quality of care they provide, just the bucks. Gross post.... what exactly are you going to contribute favorably to the patient's quality of care and positive outcome? I'm so sorry you have to do more than wave at the patient at their door.

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  4. I am a physician. I do not know the blogger personally - may be an excellent physician, may not be. But I do know that a good physician who makes good decisions for his patients can be a terrible medical coder and get paid very little for his/her efforts as a result. While the blogger's language may appear callous and cynical to an outsider, his coding advice is actually very helpful and factually/legally correct.

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  5. The OP does care about the patient - he is pointing out the most time efficient way to spend more time with the patient instead of filling paper with ink (while still getting paid).

    ReplyDelete

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