How To Bill CPT 99233 Coding Clinic: High Level Hospital Follow up

Now comes the 99233, the highest level hospital follow up visit. The lawyer garbage is being regurgitated here verbatim.

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.  Now onto the 99233,  the highest level code for an inpatient hospital follow up code. This code becomes complicated, much more than the other two and you must pull out your calculator, because you'll have to do some math.

How does the AMA define the 99233?

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 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 unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit.

35 minutes?  Really?  In my state, a 99233 pays about $86 and change.  That works out to $147 dollars an hour.  And that's before overhead.  When you make a comparison with other fields in medicine, payment rates for cognitive medicine are insulting.  And they are also insulting when compared with other  technically skilled fields that require years of post secondary education and continuing education.    My lawyer charges me double that rate.  But as we know, the rules aren't based on time, they are based on adding and subtracting and documenting the correct words.  As CMS likes to say "right care, right time, every time",  I offer my own version. Document the "right words, right time, every time."  It's the game of coding. You live and die by the game.   Here goes.  The following is my yellow card that I carry with me for every possible  follow up encounter that I bill for.  Because the rules are too complicated to remember, I must constantly remind myself.

Click on image to make larger

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 99233 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 to be compliant with the coding police.

History

1) 4 elements of the HPI (Character, onset, location, duration, associated S/Sx etc...)

     OR  

    the status of 3 chronic medical conditions (HTN-stable, COPD-stable, CAD-stable)

AND you need to document 

2) 2 ROS (no CP, no SOB)

AND you need to document

3) 1 area from Past medical or family or social history ("medications reviewed" should cover this)

Physical

1995 guidelines state extended exam of the affected body area(s) and other symptomatic or related organ systems. 

I don't know what defines "extended"  so I never use the 1995 guidelines

1997 guidelines state more clearly  6 areas with 2 bullets each, or 2+areas with 12 bullets total.

Your possible areas are (general, eyes, ENT, neck, respiratory, cardiovascular, chest/breasts, abdomen, GU, lymphatic, musculoskeletal, skin, neuro, mental status)

Decision Making  You need 2 out of the following 3 to be considered 99233 compliant

1)  Diagnosis (4 points)  Look on my yellow card

2)  Data  (4 points)  Look on my yellow card

3)  High Risk   look at the bottom of my yellow card for a sampling of the most common high risk things that qualify.  The actual risk table was too big to get on one card, so I sacrificed the less common things.  Here is the actual risk table.  If you do  any of the high risk categories, it counts overall as a high risk encounter.

click on image to enlarge

In my thought process for a patient to be billed a level three,  they almost always have to have some sort of new issue going on.   That's a general rule I use when trying to decide what level to code.   But the coding guidelines mean that's not always necessary.  I almost always include medical decision making plus either history or much less commonly the physical when billing a 99233.  For me the vast majority of times that I bill a 99233 is from a high level history and a high level decision making component.  I just can't remember 12 bullet points in 6 areas or 2+ areas and 12 bullets for the physical.  It's just too complicated  While the rules state that you only need two out of three (history and physical, history and decision making, or physical and decision making),  I almost always limit myself to history and decision making making.  It's just easier for me to do this.

So when I come upon a chart of a patient,  one of the first questions I ask myself is,  "Are there any new issues that have arisen since my encounter the previous day?"  If the answer is yes,  I can almost always achieve a level 3, 99233.  If the answer is no,  I review the chart, issues, and conditions to see if the patient could qualify regardless.    You need to make note that on my yellow card, under the diagnosis section,  I have listed a 2 point maximum for established problem, stable or improved.  This is wrong.  There is no maximum.  Without wasting more of your time, here are some examples of a 99233 hospital follow up note, in S.O.A.P note format

Using History and Physical (remember 2 out of 3)

S)   meds reviewed (1 PMFSH)

      RLQ abdominal pain, sharp, started yesterday, constant  (4 HPI)

      no CP, no SOB  (2 ROS)

O)  120/80   80   Tm 98.6

     Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness,  no clubbing, no synovitis, no rash (6 areas, 12 bullets)

A)  nothing needed

P)  nothing needed

or you can substitute the status of three chronic medical conditions for your 4 HPI and you would get

S)  meds reviewed (1 PMFSH)

      no CP, no SOB  (2 ROS)

O)  120/80   80   Tm 98.6

     Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness,  no clubbing, no synovitis, no rash (6 areas, 12 bullets)

A)   HTN-stable  (status of 3 chronic medical conditions)

       COPD-stable

       CAD-stable

P)  Nothing needed

Using physical exam and decision making (remember 2 out of 3)

S)  Nothing needed

O)  120/80   80   Tm 98.6

     Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness,  no clubbing, no synovitis, no rash (6 areas, 12 bullets)

Labs INR 1.7  on coumadin (High Risk).  CXR film personally reviewed-normal (2 points-Data).  Discussed antibiotic options with Dr Smith (2 points-Data).

A)Nothing needed

P) Nothing needed.

In this example I achieved a 99233 in the medical decision making because I achieved 4 points in the data section (two points for discussing with Dr Smith,  two points for "personally reviewing" a chest xray).  I also got high risk for "drug therapy requiring intensive monitoring for toxicity".  Coumadin is a drug that I follow for toxicity by drawing levels.  I had 12 bullets in 6 organ systems on the physical exam.  I have coded appropriately for a 99233.

Another example of a 99233 from physical exam and medical decision making:

S)  nothing needed

O)  120/80   80   Tm 98.6

     Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness,  no clubbing, no synovitis, no rash (6 areas, 12 bullets)

A)  1)  Afib,  rate controlled, improved, on coumadin,  INR 1.7

      2)  Acute HTN,  improved

      3)  Uncontrolled DM,  improved

      4)  Acute systolic HF,  improved

P)  Nothing needed

In this example  the decision making achieves 99233 level by documenting the status of 4 established problems  (Afib, HTN, DM, HF).  I get one point for each one, for a total of 4 points.  I also get High risk for documenting "drug therapy requiring intensive monitoring for toxicity"  That gets me 2 out of 3 areas for decision making in the 99233.  And that's all I need.  Along with the 12 bullets in 6 systems, this constitutes a 99233.

I could also have this:

S) nothing needed

O)  120/80   80   Tm 98.6

     Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness,  no clubbing, no synovitis, no rash (6 areas, 12 bullets)

INR 1.7 on coumadin

A)  hypoxemia-New issue

P)  get CXR, ABG

In this example high risk decision making is achieved by documenting one new issue that I plan to work up  (hypoxemia).  That gets me 4 points in the diagnosis section.  And I get high risk for  "drug therapy requiring intensive monitoring for toxicity"--coumadin.  2 of 3 in the decision making at the highest level, along with the 12 bullets in 6 organ areas gets me a 99233.

But I hate using physical exam to achieve my documentation levels, because in all honesty, I rarely do, nor need to do 12 bullets in 6 organ areas.  It's much easier to achieve 99233 by using the history and decision making.  So here goes.

Using History and Decision Making (remember 2 out of 3)

S)   meds reviewed (1 PMFSH)

      RLQ abdominal pain, sharp, started yesturday, constant  (4 HPI)

      no CP, no SOB  (2 ROS)

O)  nothing needed

       INR 1.7 on coumadin

A)  hypoxemia, New

P)  Check ABG, CXR

In this example,  again,  high complex decision making was achieved by documenting a new problem (4 points in diagnosis section)  and high risk for "drug therapy requiring intensive monitoring for toxicity- coumadin. The history component is compliant as well.

How about:

S)  meds reviewed (1 PMFSH)

      no CP, no SOB  (2 ROS)

O) Nothing needed

A)  1)  DM-stable

      2)  HTN-stable

      3)  chronic afib-stable

      4)  hypoxemia-new

P)  Discussed code status today.  Patient wishes to be a DNR.  Check CXR

In this example the status of 3 chronic medical conditions substitutes for the 4 HPI elements in the history.  My history component is 99233 compliant  My decision making is high risk (writing DNR), and my new issue (hypoxemia) gets me 4 points in the diagnosis section.  So I am highly complex decision making as well.  This is a 99233 note.

One more example:

S)   meds reviewed (1 PMFSH)

      RLQ abdominal pain, sharp, started yesturday, constant  (4 HPI)

      no CP, no SOB  (2 ROS)

O)  Nothing needed

Hgb 13.6

EKG tracing reviewed- sinus rhythm without ST or TW changes

Discussed CXR findings with the radiologist

A)  Patient on a PCA for back pain,  no changes today

P)  Nothing else needed

In this example my history is 99233 compliant.  My decision making gives me 4 points for data section by reviewing lab (1 point),  personally reviewing EKG  (2 points) and discussing the CXR with the  radiologist (1 point).  I get high risk for managing IV narcotics (PCA)

There you have it folks.  I've tried to break it down as simple as possible.  But this shit ain't easy.  My  yellow card is a life saver.  I have no concerns, ever, about over billing.  It just doesn't even cross my mind.  And this card is one reason why my ratio of level 2 to level 3 even within my group is probably double.  Nation wide,  I'm sure I'm shifting the bell curve to the right  because all the scared doctors out there refuse to get paid for their service.  There is a giant fear of getting audited by the Medicare National Bank.  Since the vast majority of my billing is follow up codes,  dotting your i's on these codes can make a huge difference in how you bill and how you collect.   I am fairly certain I would pass an audit with flying colors every time.    And my yellow card is the reason why.

Happy coding all.

You can see much more here in my coding lectures or earn CME here.