CPT® 99232: Detailed Explanation of Mid (Level 2) Progress Note Hospital Follow-Up Subsequent Care Code.

My first medical coding clinic was the 99231.  In this post,  I explain CPT® 99232, the mid level hospital follow up code.  Before I begin my discussion, 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 reference tab for access to these detailed explanations.    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.

How does the AMA define a 99232?  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: 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. 

Below is my E/M pocket reference card based on my interpretations of the 1995 and 1997 CMS guidelines that I use and reference for every single patient I see in the hospital.  I carry this  with me at all times  to determine what my documentation supports.  If you need to learn the  fundamentals of hospital follow up coding see my 99231 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

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

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. The guidelines don't really clarify what "up to 7 systems" means. So It's hard to justify exactly what that means. I use two organs systems as the bare minimum. OR

•  1997 guidelines require 6 bullets. 

DECISION MAKING

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

1) Diagnosis:  3 points (This is why I carry my quick reference E/M card at all times)

2) Data:  3 points (My coding card has helped guide me for years with this one)

3) Risk:  Moderate. (You'd be amazed, daily, at what your note qualifies just based on risk. )

I can achieve a minimum 99232 in almost every patient through sound hospital based  documentation.  For hospitalists or any physician providing an inpatient encounter, it's almost impossible not to meet the criteria of a 99232 at a minimum, every time.  Remember, 2 out of 3.  You should almost never be billing a 99231 encounter because based on the risk componenet alone, talking with another health care provider and reviewing one lab will get you moderate medical decision making just like that.  

So what would a level two 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 (1 HPI),  no SOB (1 ROS)

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

Alert, reg pulse, no wheezing, no leg edema, no rash (6 bullets)

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, reg pulse, no wheezing, no leg edema, no rash

A)  HTN, stable

COPD, stable

CAD, stable

P)  Nothing needed.

A 99232 can also be achieved by documenting history and medical decision making or physical and medical decision making that meets the 99232 threshold.  Most physicians should almost never bill any hospital follow up code below a 99232 unless you aren't documenting the work provided.  Most patients will meet the criteria of a 99232 every time.  You just need to know  what to document on the work you are already providing.  You can see much more in my free lectures on medical E/M billing.

LINK TO BEDSIDE E/M CODING CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital: (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic: (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high definition view