CPT® 99233: Detailed Explanation of High (Level 3) Progress Note Hospital Follow-Up Subsequent Care Code.

Now comes the 99233, the highest level hospital follow up visit. Before I begin 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. You can find access to these explanations in my hospitalist resource center.   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. 

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?  Reference the AMA's CPT 2013 Standard Edition on Amazon as the definitive publication 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: 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.

The following is my E/M pocket reference card based on my interpretations of the 1995 and 1997 CMS  guidelines that I carry with me to help me understand what my documentation support.  If you need more understanding of the basics of hospital follow up E&M coding, see my first coding clinic on coding a 99231, the low level hospital followup, for a more thorough explanation (see link below). 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 and with the requirement that all work be medically necessary. 

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)

PHYSICAL EXAM

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)  This is where you need my quick reference E/M card 

2)  Data  (4 points)  I use my coding card every day for this

3)  High Risk   And this too. I under codedd for years based on my lack of understanding of the risk component.  Not anymore as I carry my pocket sized coding card everyday and reference it on every patient.   


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 is 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 for the 99233, but, again, that's not necessary if the physical exam meets 99233 coding documentation requirements.  


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.  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)   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)   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)   RLQ abdominal pain, sharp, started yesterday, 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 with further workup planned.  )  and high risk for "drug therapy requiring intensive monitoring for toxicity- coumadin. The history component is compliant as well.

How about:

S)  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 due to poor prognosis.  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 with further workup planned.  So I am highly complex decision making as well.  This is a 99233 note.

One more example:

S)  RLQ abdominal pain, sharp, started yesterday, 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 is complicated stuff.  It took me years of daily diligence and carrying my E/M pocket reference card based on CMS guidelines  with me at all times for a constant reminder of how to get it right, every time.   You can see much more in my free lectures on E/M coding in the hospital. 

LINK TO E/M POCKET 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