ED Coding and Reimbursement Alert

Rules for reporting these encounters differ from rules for other E/M services
 
When the ED physician provides subsequent hospital care to a patient, the onus is on the coder to choose the proper level of evaluation and management service based on the physician's notes -- and this can be a very challenging undertaking.
 
ED coders often under-report subsequent hospital care services, resulting in a lower payout and hurting the facility's overall finances. This could occur if a coder fails to realize that she need not satisfy all of the E/M components to report the subsequent care codes, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.
 
Another issue: As if under-reporting weren't enough of a potential problem in subsequent hospital care coding, the coder could also over-report subsequent care service if she does not include documentation to back up her code choice, which could lead to denials and suspicious payers.
 
There are some tricky aspects to subsequent hospital care coding, but if you pay attention to the special rules and observe the documentation guidelines, you can ethically max out your revenue for these services.
 
2 out of 3 Ain't Bad for These E/M Codes

Your ED physician may provide subsequent hospital care to patients for several reasons, including contractual obligations, after-hours resource limitations, or general clinical responsiveness.
 
For example: The ED physician is needed to assess a floor patient who is having shortness of breath or chest pain. Frequently these -floor responses- will not meet the full requirements for reporting either a critical care code or a consult code.

Choose From 3 E/M Levels for Subsequent Care

When you are choosing a service level for these encounters, you-ll decide among these codes:

- 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; medical decision-making that   is straightforward or of low complexity

- 99232 -- ... an expanded problem-focused interval  history; an expanded problem-focused examination;  medical decision-making of moderate complexity

- 99233 -- ... a detailed interval history; a detailed   examination; and medical decision-making of high   complexity.

But be careful when selecting a code from this family, because 99231-99233 claims have different reporting rules than the standard ED E/M services.
 
For most ED E/M services, such as 99281-99285 (Emergency department visit for the evaluation and management of a patient ...), you must meet all three key components in their E/M description -- history, physical exam, and medical decision-making (MDM). To claim 99231-99233, however, the physician only has to meet two of the three key E/M components, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.
 
Example: An ED physician provides subsequent hospital care to a patient. The notes indicate that he performed an expanded problem-focused interval history with a problem-focused examination. MDM was of moderate complexity.

-You only need to have two out of three elements, so if the notes indicate [level-one] exam, but indicate interval history and MDM are level two, then that's all you need,- Brink says.
 
On the claim, report 99232 for the service.

Carefully Check Documentation on Claim

A major hurdle when coding subsequent care claims is that everyone interprets the definitions for each care level differently. 
 
-The problem that we run into with [coding] scenarios, including the clinical examples provided by the AMA in CPT 2006, is that not all doctors agree- about what constitutes level-one, -two and -three subsequent hospital care services, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga.
  
-Also, each [physician] documents differently, and regardless of the complaint or physician actions, it all comes down to the documentation and the medical necessity of the encounter,- she says.

Having Trouble? Start With Interval History

If you are having trouble deciding on the service level for 99231-99233 claims, start with the interval history, Brink says. If the physician does not document an interval history, ask him for one. It will make your subsequent care claim stronger, Brink says.
 
How? The interval history is the first step toward determining medical necessity, which is vital to proving the service level on subsequent care claims.
 
-Even though the code set 99231-99233 uses two out of three for history, exam, and MDM, interval history sets up the medical necessity for performing the type of exam and resulting MDM,- Brink says.

Consider This Example

The physician's notes state, -Patient's emphysema unchanged from yesterday, stable.- This would not necessitate a detailed or comprehensive exam or a high MDM, Brink says. -Probably a 99231 or 99232 level of service,- she says.
 
But, if interval history indicated -Patient with chronic emphysema has worsened since yesterday, breathing labored, in acute distress, pain level +8,- the physician would perform a more detailed exam and more complex MDM (for example, because the physician prescribed medication, ordered more lab tests, etc.).
 
An encounter with this interval history -- if properly documented -- is likely to be a 99233 service. But you have to fortify the claim with documentation or it will end up in the denial pile.
 
-If notes fail to tell everything the physician performed, the documentation won't support the correct level of service,- Brink says.