99233 CPT® Code Description, Progress Notes, RVU, Distribution.

This 99233 Current Procedural Terminology (CPT®) lecture reviews  the procedure code definition, progress note examples, RVU values and national distribution data.  CPT® 99233 is the highest of the three Healthcare Common Procedure Coding System (HCPCS) inpatient hospital follow up codes.  The low level CPT® 99231 and mid level CPT® 99232 subsequent care codes are described elsewhere on The Happy Hospitalist as part of a complete collection of CPT® lectures I have written previously .  I am a board certified internist with over ten years of clinical experience in a community hospitalist program providing physician services at 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 evaluation and management coding requirements. These lectures were written  several years ago, but the information remains highly relevant today.  


These lectures and accompanying coding resources are used by myself to make sure I stay compliant with the rules and regulations of the Centers for Medicare & Medicaid Services (CMS).   All CPT® lectures I have written are organized in one easy-to-find location on  Pinterest.   You don't need to be a Pinterest member to see all of my CPT® procedure lectures. As you are learning to understand CPT® E/M coding, always remember that it is your responsibility to make sure your documentation supports your level of service you are submitting for reimbursement. How much you write in the chart  should not be used to determine your level of service. What matters most are the details of your documentation as defined by the rules discussed in this and other CPT®  lectures. The CMS 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

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. Details of these files can be found in my hospitalist resource section at this link.   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 on Amazon by clicking on the picture file.   CPT® 99233 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 99233 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: 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.
This code can be billed based on time under certain circumstances. I have detailed those discussions at the link provided. Note however that documentation of time is not a required component to stay compliant with CMS regulations. If this code is billed without time as a consideration, CPT® 99233 documentation should be based on the requirements stated 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. I'll state it again.  For hospital follow up progress notes, only the highest two out of three components from history, physical and MDM are needed to determine the correct level of service provided. I have detailed below a  discussion that explains the absolute minimum requirements required to remain in compliance with CPT® code 99233.  Also remember that a face-to-face encounter is required for all visits by CMS beneficiaries.
  • Detailed interval history: Requires 4 elements of the history of present illness (HPI) OR documentation of the status of 3 chronic medical conditions AND 2 review of systems (ROS).  No past medical history or family history or social history is required (PMFSH).   
  • Detailed physical exam
    • 1995 E/M guidelines require an extended exam of the affected body area(s) and other symptomatic or related organ systems.   These terms are poorly defined and I feel they are open to great variation of interpretation. Note the wordage difference with body area vs organ systems.  They are not the same.  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.  I recommend instead to consider using the 1997 guidelines that provide better clarity. 
    • 1997 E/M guidelines more clearly define the need for a physical exam that includes at least 6 areas with 2 bullets each, or 2+ areas with 12 total bullets.  
  • High complexity medical decision making (MDM): This is split into three components. The 2 out of the 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 for high complexity MDM? 
    • Diagnosis (4 points) 
    • Data (4 points) 
    • Risk (high) The table of risk can be found on page 37 of the CMS E&M reference guide.
The medical decision making point system is quite complex. I have a detailed reference to it on my E/M pocket cards described below. These cards help me understand everyday what type of care my documentation supports. I carry these cards with me at all times and reference them all day long. They  help me understand what level of service my evaluation qualifies for.

CLINICAL EXAMPLES OF 99233

 

Here are my general thoughts on billing a 99233 follow up note:  They almost always have some sort of new issue going on.   That's a general rule I use when trying to decide whether or not to code this level, but that's by no means always the case.  When billing a level three subsequent care note, I usually try and include medical decision making in my coding decision.  As I said above, MDM is not required because only 2 out of three for history, physical and MDM must qualify for a level 3 99233.  However, I feel, if I am doing a physical exam that warrants 12 bullet points, it's because they have an issue or are sick enough to qualify for the highest MDM category.

When I come upon a chart of a patient,  I want to know if there are any new issues that have presented since my last evaluation.    If the answer is yes,  my documentation can usually support a level 3 progress note.  Remember, the rules are not based on how much is written, but rather what is written.    If the answer is no,  I review the chart and medical conditions to decide whether the patient would qualify anyway.  I think physicians universally underestimate risk as it applies to E/M coding.  Many of our patients should be categorized as high risk and billed as such if other documentation supports the highest level of medically reasonable and necessary service.  Listed below are some examples of 99233 hospital follow up notes in subjective, objective, assessment, plan (SOAP) format.
S)   RLQ abdominal pain, sharp, started yesterday, constant  (4 HPI)
      no CP, no SOB  (2 ROS)
O)  120/80   80   Tm 98.6n (3 vitals is 1 organ)
     Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness,  no palpable abdominal masses, no peritonitis signs, no clubbing, no synovitis, no rash (6 areas, 12 bullets)
A) nothing needed
P)  nothing needed
This note meets criteria for a level three CPT® 99233 progress note based on history and physical.  Again, the highest two out out of three from history, physical and MDM documentation are used to define the level of service provided.  The care must be medically reasonable and necessary.  Some folks argue that MDM must be included as one of the three components for a high level E/M visit.  The rules and guidelines we are asked to follow do not state that.  Some may argue that 12 bullet points are not medically necessary without high complex medical decision making.  As a practicing hospitalist of ten years, I would consider that assumption as inaccurate.  

There are many patients that require intensive physical exam that may not have criteria for high complexity MDM.  Documentation is vitally important to avoid any questions in an audit situation.  If you feel an extensive physical exam is warranted everyday, document your reasoning why.  That's what determines medically reasonable and necessary care.  And always remember, when submitting payment to CMS, documentation must support at least one ICD (the problem) code from which to link the CPT® code to.  I usually recommend documenting at least one problem in the note, unless the problem can be inferred elsewhere in the chart (such as in the orders as an indication for a test).    Here's another example of a level 3 hospital progress note below:
S)   no CP, no SOB  (2 ROS)
O)  120/80   80   Tm 98.6 (3 vitals as 1 organ system)
     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, no changes planned (status of 3 chronic medical conditions)
       COPD-stable, no changes planned
       CAD-stable, no changes planned
P)  Nothing needed
Again, this progress note meets criteria for a level 3 based on history and physical exam once again.  However, in this case, the status of three chronic medical conditions (which have relevance to the patient's condition) substitute for four elements of HPI.   Documenting stable HTN, CAD and COPD with no changes planned is considered an appropriate substitute for 4 HPI.  I would only consider using chronic conditions that have relevance to the patient's condition.  Again, if there is any question about their relevance, document your thought process.  The reason many physicians fail audits is not because they are committing willful fraud but rather because they commit omissions of documentation.  They fail to explain their reasoning behind their decisions. Here is another level 3 progress note below:
S)  Nothing needed
O)  120/80   80   Tm 98.6 (3 vitals is 1 organ)
     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 for drug management requiring intensive monitoring for toxicity).  CXR film personally reviewed-normal (2 points-Data for personal review of CXR).  Discussed antibiotic options with Dr Smith (2 points-Data for discussion of case with another healthcare provider).
A) Nothing needed
P) Nothing needed.
In this progress note example a level three is achieved based on documentation bullets from the physical exam and medical decision making.  Nothing is needed from the history component. Remember, two out of three for follow up hospital notes.   I documented a 99233 in the medical decision making because I achieved 4 points in the data section with 2 points for discussing with Dr Smith and  2 points for personally reviewing the CXR.  I also got high risk for drug therapy requiring intensive monitoring for toxicity.  Coumadin is a drug that I follow for toxicity by drawing INR levels. I think Coumadin use in the hospital is high risk, under most circumstances, and I make sure my documentation supports my thought processes on why I consider it so.  Remember, medical decision making guidelines also require a determination of the highest  2 out of 3 for data, diagnosis and risk.  I received high complexity medical decision making based on data and risk.   I had documentation of at least 12 bullets in 6 organ systems on physical exam.  Therefore, this note meets criteria for a CPT® 99233. One does not need to write volumes of information to meet criteria for high complexity care.  Here is another example:
S)  nothing needed
O)  120/80   80   Tm 98.6 (3 vitals is one organ)
     Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness,  no clubbing, no synovitis, no rash (at least 6 areas, 12 bullets)
A)  1)  Afib,  rate controlled, improved, on Coumadin,  INR 1.7 (High risk for drug therapy requiring intensive monitoring for toxicity)
      2)  Acute HTN,  improved  (4 points for Diagnosis for 4 stable conditions)
      3)  Uncontrolled DM,  improved
      4)  Acute systolic HF,  improved
P)  Nothing needed 
This note meets a high level 99233 progress note based on physical exam and MDM again.   Remember, 2 out of 3.  History does not matter here.  The physical exam achieves level three based on 12 bullets in at least 6 areas.  The MDM is high complexity based on the diagnosis and risk components.  I get 4 points for documenting 4 stable chronic medical conditions with AF, HTN, DM and CHF.  I get high risk for documenting high risk drug management with warfarin.  This is a level three progress note.  The care and documentation is medically reasonable and necessary.  These are hospitalist patients that I feel we under code every day because we fail to appreciate how complex they are and we fail to document work we are already doing to indicate complexity.  Here's another 99233 example:
S) nothing needed
O)  120/80   80   Tm 98.6 (3 vitals is one organ)
     Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness,  no clubbing, no synovitis, no rash (at  least 6 areas, 12 bullets)
INR 1.7 on Coumadin (High risk for drug management requiring intensive monitoring for toxicity)
A) hypoxemia-new issue (Diagnosis-4 points for new problem with further workup planned)
P)  get CXR, ABG
This is a high level subsequent care progress note based on physical exam and MDM.   The physical exam has at least 12 bullet points in 6 areas.  The MDM is high complexity based on diagnosis and risk.  I get 4 points for addressing a new issue with further workup planned.    In addition, I get high risk for drug therapy requiring intensive monitoring for toxicity.  This is a level three progress note.  Note once again how compact the note is.  What is written matters.  How much is written does not.  Our guidelines tell us so.  Here is another example of a 99233 progress note:
S)   RLQ abdominal pain, sharp, started yesterday, constant  (4 HPI)
      no CP, no SOB  (2 ROS)
O)  nothing needed
       INR 1.7 on Coumadin (high risk drug management)
A)  hypoxemia-new (Diagnosis-4 points for new problem with further workup)
P)  Check ABG, CXR
Level three is achieved using history and MDM.  My history qualifies for a 99233 based on 4 HPI and 2 ROS.  My MDM qualifies based on diagnosis and risk.  I got 4 diagnosis points for a new problem with further workup planned.  I got high risk for Coumadin management.  Did you ever think you could write so little and still bill an appropriate 99223 based on the guidelines we have been given to follow?  Here is another example using history and MDM:
S)  no CP, no SOB  (2 ROS)
O) Nothing needed
A)  1)  DM-stable, no changes planned  (status of 3 chronic medical conditions in place of 4 HPI)
      2)  HTN-stable, no changes planned
      3)  chronic afib-stable, no changes planned
      4)  hypoxemia-new (Diagnosis-4 points for new problem, more workup planned)
P)  Discussed code status today.  Patient wishes to be a DNR due to poor prognosis.(high risk for DNR discussion, order for DNR)  Check CXR ( Data-1 point for radiology)
In this example, I substitute the status of three chronic medical conditions for the 4 HPI.  The MDM is high complexity for risk and diagnosis.  Discussing DNR and writing an order for such can qualify for high risk under the risk table guidelines.  In addition, 4 points under diagnosis of a new medical condition with further workup planned meets high complexity care criteria.  This is a level 3 progress note. 
Here is one last example of a CPT 99233 based on history and MDM:
S)  RLQ abdominal pain, sharp, started yesterday, constant  (4 HPI)
      no CP, no SOB  (2 ROS)
O)  Nothing needed
Hgb 13.6 (Data-1 point)
EKG tracing personally reviewed- sinus rhythm without ST or TW changes (Data-2 points for personally reviewing tracing or image)
Discussed CXR findings with the radiologist (Data-1 point for discussing test with performing physician)
A)  Patient on a PCA for back pain,  no changes today (High risk for IV opiate management)
P)  Nothing else needed
The history of 99223 compliant with 4 HPI and 2 ROS.  The MDM is high complexity based on data and risk.  The data has the required 4 points by 1 point for reviewing lab, 2 points for personally interpreting an EKG tracing and 1 point for discussing the CXR with the radiologist.  In addition, the case is high risk based on IV opiate therapy, a high risk therapy based on the risk table guidelines we have been given for compliance.  

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).  Here is their analysis. I do not believe this data uniquely represents hospitalist data as opposed to 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® 99233 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 99233 had 22,285,570 allowed services in 2011 with allowed charges of $2,254,038,317.46 and payments of $1,789,718,423.32.

99231-99233 National Procedure Summary File CMS 2011


RVU VALUE

 

How much money does a CPT ® 99233 pay in 2014?  That depends on what part of the country you live in and what insurance company you are billing.    All CPT® codes are paid in relative value units (RVUs).  I have previously discussed the complex nature of RVUs.  You can find that discussion here.  For raw RVU values, a CPT® 99233  is worth 2.91 total RVUs.  The work RVUs are 2.0.  A complete list of RVU values on common hospitalist E/M codes can be found here.  What is the 99233 Medicare reimbursement?  In my state, a CPT® 99233 pays about $99 in 2014.  The 2014 RVU dollar value conversion rate is 35.8228. 

You can see many more of my  E/M lectures here.  I've tried to make this complex process as simple as possible to help others understand how important documentation is to stay compliant and to get appropriately paid for the work they are providing.  It took me years of daily diligence and carrying my E/M pocket reference card around  with me at all times to get comfortable with medical billing and coding.


LINK TO E/M POCKET CARD POST


EM Pocket Reference Cards Using Marshfield Clinic Point Audit



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12 Outbursts:

  1. Do you need to actually write how much time was spent in addition to all of the above criteria for a 99233?

    ReplyDelete
  2. nope. there is a way to document 99231, 99232, and 99233 based on time. I'll explain that at some point. It's one or the other. Again, very strict rules.

    ReplyDelete
  3. please respond!!
    So, say I document enough for a level 3, but the patient issues are not truly complex? (COPD, improving, DM uncontrolled but not wildy so, nausea, etc) can I still bill level 3? also, even if I document 99232 and then the complexity is even less? I.E. DVT staying in house till INR theraputic? or chronic panreatitis, here for pain meds (like always), probably doesn't really have pancreatitis, planning on kicking them out tomorrow? no change in therapy? (already on oral meds?)still on IV? or Off IV? either way! please help!?

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  4. complexity is determined by the rules as set forth by the Medicare National Bank. Complexity is not determined by how complex you think the problem is.

    For example, managing coumading for an ENT doc may be very complex. Managing coumadin for a PCP may be easy.

    Medicare considers drug management that requires frequent levels to be checks high complexity.

    The answer to your question is to follow the rules and code what for the work that you do based on the established rules. You don't decide what is complex or not, Medicare does.

    ReplyDelete
  5. I think Past medical or family or social history requirement is waived for follow up notes. Only HPI and ROS are needed. What do you think Happy? Also do we need a Chief complaint in a progress note??

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  6. Hey happy,
    what if you have a specialist such as cards on the case, addressing for example afib that developed in a pneumonia admit - can you still claim credit?

    ReplyDelete
  7. To charge 99233 by time you need to spend more than 35 minutes with your visit and more than half of that time at bedside and document it in your note.

    ReplyDelete
  8. Question for you. If you write a social history, family history, review of systems with 10+ things in it, and a PMH of 2-3 problems, do you get points for each of those items, and does it automatically qualify you for a comprehensive history?

    Thanks,

    Matthew

    ReplyDelete
  9. Mathew, are you talking about admission codes 99221-99223 or hospital follow up 99231-99233. The rules are very different.

    ReplyDelete
  10. Actually, I am talking about the detailed history or comprehensive history for 99214, 99215 outpatient (sorry I may have posted here). In other words, if I program each note to have 10 ROS, Family Hx, Social Hx, PMH of at least 3 problems, along with a chief complaint with quality, duration, etc. is that automatically a "comprehensive" history?

    Thanks,

    M

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  11. how do you differentiate established problems for decision making from chronic problems for HPI

    ReplyDelete
  12. When you say HPI do you mean complaints the patient has today or what he came in with

    ReplyDelete

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