Anesthesia Coding Alert

The Health Care Financing Administration (HCFA) is watching providers usage of evaluation and management (E/M) codes and paying special attention to codes CPT 99214 and CPT 99233. In a letter to physicians earlier this summer, HCFA warned that auditors would begin closely monitoring these two codes. Coding professionals should be sure any anesthesia E/M services being billed with these codes are legitimate, and that the patients record includes documentation to back up the use of these two codes.

The Codes in Question

One of the codes cited by HCFA relates to office or outpatient evaluation, and the other deals with subsequent hospital care. The definitions are:

99214 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity)

99233 (subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history; a detailed examination; and medical decision-making of high complexity)

HCFA auditors say 99214 and 99233 accounted for a large portion of coding errors in the last two audits. Their letter confirmed that documentation for many of the services was only sufficient to support the services covered by codes 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem- focused examination; and straightforward medical decision-making) and 99231 (subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem-focused interval history; a problem-focused examination; and medical decision-making that is straightforward or of low complexity), which are both of lower complexity than 99214 and 99233.

What Happens Now?

Evaluation and management of patients usually is included in the global fee for most anesthesia services provided. Some practices rarely use them and will not be affected by the scrutiny. But with the growth of pain management practices, more providers are using E/M codes more frequently. Providers and coders should pay close attention to the criteria for each E/M code to ensure that the best-fitting codes are billed for the situation.

Appendix D of CPT 2000 lists clinical vignettes that include examples of the use of code 99214 for anesthesia and pain management. One of the four clinical vignettes states that 99214 might be reported for an established patient with new onset of low back pain. All of the vignettes seem to focus on established pain management patients with some level of complication, like the onset of new pains.

In the anesthesia examples, the vignettes indicate that 99214 service might be reported for treatment plans with complications that require additional effort on the part of the physician to determine and implement a revised care plan resulting in moderate complexity. Curtis Udell, CPAR, CPC, president of EMPHYSYS, a physician and compliance billing firm in Cumming, Ga., points out that under the E/M Table of Risks management options, the provision of prescription medications is considered to be of moderate risk or complexity.

Unfortunately, the appendix does not include any anesthesiology vignettes for 99233, Udell adds. But physicians can look to the E/M definitions for 99233 to better understand the conditions for which they could report 99233. The detailed code 99233 requires high complexity and the nature of the specific problem (i.e., severity) such as [an] unstable patient [who] has developed a significant complication or a significant new problem.

When billing for codes 99214 and 99233, the most important factor to consider is whether all criteria regarding the patients history and physical, as well as the providers level of decision-making, are fulfilled. Some coders opt to not bill either of these E/M codes for Medicare patients when the codes would be filed in addition to another code for a more comprehensive service.

If E/M services that qualify for codes 99214 and 99233 are performed in conjunction with an injection like 62310 (injection, single [not via indwelling catheter] not including neurolytic substances, with or without contrast [for wither localization or epidurography]. of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic), or 62311 (lumbar, sacral [caudal]) the patient must have new symptoms or a significant change in condition since the last visit before the E/M codes can be used.

Distinguishing Between Code Levels

In general, providers should keep in mind that codes 99212 and 99231 are problem-focused and include scenarios like seeing a patient for leg pain. If you see a patient for sciatica and do an exam that confirms this and obtain a history that confirms this, you are only doing problem-focused work.

Codes 99214 and 99233 are higher-level codes and more detailed (i.e., the patient has generalized muscle pain). The provider is assessing the entire patient and completing a detailed exam, history and decision-making. For example, these codes can be used in situations when an intensive care unit (ICU) patient who is not improving, is not on ventilator management, and needs care but does not meet the critical care code (codes 99291 and 99292) guidelines. The exam and decision-making should meet the guidelines for E/M.

Documentation of both detailed and comprehensive services can bedevil the best physicians, says Udell. My audits of physician charts have shown that some physician documentation of the four history elements (chief complaint, history of present illness [HPI], review of systems [ROS] and patients family history [PFS-Hx]) continues to be problematic. Simple omissions of one or more items within the four patient history elements quickly result in level-of-service code reductions.

Udell offers these points for physicians to focus on when considering codes 99214 and 99233:

Separate the history into its four elements, including
a separate chief complaint.
The HPI must define at least four of the eight HPI
items.
The ROS must define at least two or more organ
systems.
At least one of the three past family and social
histories must be referenced.
The exam should include the review of at least two
or more organ systems or body areas.
The service must support moderate (99214) or high
(99233) complexity.
Develop templates for physicians to compare
documented work with the chart on which they are now working on.
Include a copy of the patients care notes when the
chart is sent to the coder. The coder should verify that
the service provided supports the criteria for the level
of E/M coding requested.

Write down everything that transpired during the encounter, not just the important positive findings, but also all negative findings. Remember, youre getting measured on the work you did, not what you found, points out Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in North Augusta, S.C. You also should understand the decision-making component. Many physicians overrate the complexity of the problem, and that component is often so low that the documentation does not support the level of service if the history or exam is lacking.

Some coders and compliance professionals believe that providers may decrease their use of 99214 and 99233 because of the increased scrutiny. Their prediction is that providers will try to play it safe and use the other E/M codes instead. This may result in lower reimbursement rates, but some professionals feel it is better than being caught during an audit and accused of trying to upcode.

Other coding professionals are quick to point out that this type of downcoding is fraudulent upcoding. The top priority for providers and coders alike is to code correctly and try to avoid up- and downcoding. If extensive histories and physicals are performed, they must be thoroughly documented to get the most appropriate reimbursement.

If an internal audit reveals that documentation does not support the detailed services, then the practice should provide focused education to the providers that includes a review of the chart against an audit form to determine problem areas. This could be done through grand rounds, special coding meetings or other opportunities. Some educators recommend making overheads or handouts of some actual charts from the group to use as teaching tools (although, depending on the situation, it may be better to not identify the physician). And, as part of the Office of Inspector Generals self-disclosure policies, the practice will be asked to refund the difference between the billed code and the supported code to the insurance company if the review was retrospective.

According to Udell, While the physicians medical record documentation is always the sword or savior, when it comes to auditing, physicians also should have their E/M code utilization patterns compared to their specialty peer group, better known as benchmarking against the bell curve. Physicians should know if they are under- or over-selecting codes because the government already knows. E/M programs with reports showing results by level of service and type of service are available to help providers with their benchmarking.

This special attention to codes 99214 and 99233 is nothing new, and coding professionals should be aware of specific codes that are being audited. Callaway-Stradley says that states also have focused for some time on individual codes as an issue within that state.

The goal of anesthesia providers and coders is to submit claims with the most appropriate code for reimbursement. The tips listed above will help you determine whether it is appropriate to file a claim with codes 99214 or 99233, but always check with your local carrier for any specific questions about whether a procedure met their criteria.