EM Coding Alert

Coding Updates:

Beware These Inpatient Evaluation Red Flags

Published on Mon Jan 23, 2023

Take a deep breath after experiencing those myriad January updates.

Coders who encounter hospital-based evaluation and management (E/M) services may feel overwhelmed by all of the updates that went live in January 2023. The 2023 CPT^®overhaul means changing the coding strategies you may use while reporting inpatient evaluations.

Make sure you know how to navigate these adjustments: Keep reading for tips.

Don’t Forget: Use Time or MDM

Effective Jan. 1, 2023, when your gastroenterologist sees a patient in the hospital, you’ll use either time or MDM when you choose a code in the 99231-99233 range (Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination …).

To select the right code, use this grid outlining how to select either MDM or time:

Caveat: If you’re counting the amount of time the gastroenterologist spends on the encounter, you don’t have to stop counting when you’re tallying non-face-to-face time. CPT^®2023 states, “For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician or other qualified healthcare professional on the day of the encounter …” (source: www.ama-assn.org/system/ files/2023-e-m-descriptors-guidelines.pdf).

For instance: Suppose a 73-year-old patient is admitted to the hospital for dehydration and rectal bleeding. The gastroenterologist examines the patient and diagnoses them with diverticulitis, then prescribes intravenous (IV) antibiotics and fluids. However, when the physician returns the next day to see the patient, they require a medication adjustment to a higher dosage of the IV antibiotics. On that date, the gastroenterologist reviews the patient’s bloodwork, examines them, updates the prescription dosage, talks to the dietitian about an appropriate diet, and speaks with the family for 20 minutes. In total, the physician spends 36 minutes on the patient’s care. For this visit, you’ll report 99232 if you’re coding based on time.

Support Your Code Choices via Documentation

Documenting history, exam, and MDM is still important in 2023, even if you’re billing based on time, because the descriptors do note that the gastroenterologist should be performing a “medically appropriate” history and exam. However, it’s now also essential to make sure the documentation reflects the MDM and the time spent as well as what the GI physician did during that time.

Warning: You can’t simply ask your gastroenterologists to continue documenting like they did in 2022, because subsequent hospital care codes only required them to document two of the three key components. If they chose only history and exam, that means they didn’t feel the need to thoroughly document MDM or time — which would leave you unable to report any code at all.

Note These Red Flags

Once you’re sure your gastroenterologists have nailed their documentation using the 2023 rules, it’s a good idea to share some common red flags with your entire staff (both clinicians and coders) to ensure that you aren’t running afoul of any common issues that can attract the attention of auditors. The following are a few to look out for:

Repeating the same code level: Some clinicians get accustomed to reporting one particular E/M code level repeatedly — often without even realizing they’re doing it. In certain cases, if the documentation supports it, that might be appropriate, but most of the time, insurers (and auditors) will expect to see your GI physician reporting a range of codes depending on the patient’s specific situation. If your gastroenterologist reports all 99233s because they only see very sick patients or they report all 99231s because they like to play it safe, they are coding incorrectly. “A doctor who codes 99231 all the time is just as likely to get audited as a doctor coding 99233 all the time, based on an algorithm of what other GI practitioners bill. It’s our job to at least do internal audits to correct same-level coding before the payers do,” says Halee Garner, CPC, CPMA, CCA, certified coder for Digestive Health Partners in Asheville, North Carolina.

Additionally, undercoding, even to “play it safe” could potentially get your practice in trouble. “Undercoding is fraudulent, as it’s misrepresenting what happened during the visit. There is a risk that someone could decide your office is in violation of several statutes and flag the office for further investigation,” says Kelly Shew, RHIA, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, documentation and coding education, Olympia Medical in Livonia, Michigan.

Reporting unusual coding patterns without context: Documentation is key to your coding choices — not just so you can justify the specific codes you’re reporting on any particular date, but also so you can tell insurers the bigger picture. For instance, suppose you report 99233 for a patient on Feb. 1. Then on Feb. 2, you bill a discharge. The insurer may find it odd that you saw a patient who required the highest level of subsequent hospital care one day, and then the patient was well enough to go home the next day. This isn’t necessarily an indication of upcoding, but without documentation demonstrating the reasons behind the two codes, insurers may wonder.

Failing to document extenuating circumstances: If your gastroenterologist sees a patient with rectal bleeding due to diverticulitis as noted in the example above, the insurer may be surprised if you report 99233 for several days in a row, since that diagnosis is often relatively straightforward. But if your patient really does warrant the higher-level code, you can justify it by documenting all the extenuating circumstances that led to that. For instance, suppose the patient has heart failure, type 2 diabetes, a history of breast cancer, diabetic retinopathy, and vascular issues in their feet. Those would be extenuating circumstances that may make their care much more complex than a standard diverticulitis case and documenting them can help you justify the higher-level code.

From this, it’s clear to see that excellent documentation is the best way to avoid any potential issues with your payers or auditors. If your GI team needs to brush up on documentation for subsequent hospital visits, make sure to schedule several sessions to ensure that you don’t leave any questions unanswered.