Gastroenterology Coding Alert

The subsequent hospital care visit codes (99231-99233) are among the top 10 CPT codes reported by gastroenterologists, according to data compiled by HCFA. Although these codes are frequently reported, gastroenterologists may be underreporting the level of visit that was performed because these codes are defined in a slightly different manner than other evaluation and management (E/M) codes. To avoid underreporting, gastroenterologists should use time spent counseling and coordinating care as a gauge to help them determine the level of visit performed and use a prolonged care code to report extremely long patient visits.

High-level Interval History Not Hard to Achieve

The subsequent hospital care codes are commonly used by gastroenterologists to report daily visits to their hospitalized patients, according to Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT Advisory Panel. If you are listed as the primary care physician for a patient in the hospital, you should be seeing them every day whether he or she is stable or not.

One of the unusual features of these codes is that interval history is one of the key components, along with examination and medical decision-making that determines the level of subsequent hospital care to report. (For subsequent care codes, only two of the three key components need to be considered.) The interval history is what has happened to the patient in the past 24 or 48 hours, Weinstein explains.

Gastroenterologists may feel that it is hard to accumulate the number of elements in a patient history required by CPT and Medicare to report a high-level history. But it is not that difficult, according to Weinstein. Gastroenterologists need to remember that the highest level of subsequent care (99233) requires only a detailed interval history, not a comprehensive history as required by other high-level E/M codes. According to evaluation and management documentation guidelines issued by CPT and Medicare, a detailed interval history contains the following:

Chief complaint;

Extended history of present illness (HPI). Four or more elements, or three or more chronic or inactive conditions if the 1997 Medicare E/M guidelines are being followed; and

Problem-pertinent review of systems (ROS) extended to include a review of a limited number of additional systems (two to nine systems).

Its relatively easy to get a high-level history even when its an interval history, Weinstein says. A gastroenterologist will ask a patient with Crohns disease, for example, whats happening with his or her pain, diarrhea, or nausea and if theres been any bleeding.

For an interval history, the HPI and ROS will be the only elements considered. With the Crohns disease patient, the gastroenterologist will be checking to see if the patient is having a reaction to the steroids, checking his or her breathing and asking about any urinary symptoms or skin rash, he continues. The personal, family and social history, which is usually an element of patient history, does not have to be included in an interval history because this information isnt likely to change over a 24-hour period.

Change in Treatment Equals Medical Decision-making

When conducting an examination of the patient, medical decision making is often the other key component gastroenterologists look at when deciding what level of subsequent care to report. If I make a change to the patients medical treatment plan that reflects more complex medical decision-making on my part, it warrants a higher-level visit, Weinstein explains.

Changing multiple drug therapies for a Crohns disease patient who is on steroids and antibiotics can be an example of high-complexity medical decision-making, he continues. The gastroenterologist will have to look for complications such as anemia, rising or falling glucose levels, x-ray results or hepatic enzyme change. For patients with gastrointestinal bleeding, deciding whether the patient gets one or two units of blood could be considered high-complexity.

Complexity of Condition May Override Patient Status

Another source of confusion when determining the overall level of the visit is the note at the end of each subsequent care definition in the CPT manual regarding the patients condition. For 99231, CPT states that the patient will usually be stable, recovering or improving. For 99232, it states that the patient will usually be responding inadequately to therapy or developing a minor complication.

Gastroenterologists who code strictly on the basis of patient status may be underreporting patients who are stable but have other chronic conditions, such as diabetes or heart disease, and require more time and complex medical decision-making to evaluate. The patients problem(s) ultimately determines the medical necessity of the visit. If the patient is responding to treatment, theres not as much medical necessity for a higher-level subsequent hospital care visit, says Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J. However, multiple conditions or risk factors could increase the level of medical decision-making to moderate (99232) even when the patient is stable.

It might be unusual, however, to ask the patient every day about multiple stable conditions, Weinstein notes. Consequently, gastroenterologists should not automatically report a higher level of visit just because a patient has multiple pre-existing conditions.

Level of Visit Can Also Be Based on Time

The gastroenterologist can also code the visit based on the amount of time spent on counseling and coordinating care for the patient, Brink suggests. When more than 50 percent of the total encounter with the patient is spent on counseling and coordination of care, the gastroenterologist can report the visit based on the element of time, she says. The gastroenterologist can be counseling the patient on his or her medical problems or talking with other providers; both criteria are considered part of counseling and coordination of care. The CPT definitions for these visits also state that the time spent on the patients hospital floor can be considered in addition to time spent at the patients bedside.

In fact, with the subsequent care codes, time spent counseling and coordinating care is often the key component used to determine the level of complexity of the visit. Time is usually not a criterion for an office visit, Weinstein says. But in the hospital, I often use it as an indication for how seriously ill the patient is. If I spend 30 to 40 minutes talking with the patient, the patients family and another physician, thats going to be a higher-level visit.

If time becomes a key component, it is important to write down the amount of time spent meeting with the patient, his or her family, other physicians and nonphysician providers. The gastroenterologist should record start and stop times in the patients medical record and include a brief synopsis of what was discussed with the patient or other providers, Brink says.

Using Prolonged Services With Multiple Visits

A gastroenterologist may visit an acutely ill patient more than once a day, but can bill for only one subsequent hospital care visit a day. In this situation, however, report the highest level of subsequent care. If I see a patient twice in one day, I report the highest level of subsequent care code, Weinstein says. Seeing someone twice in one day means that the patient must be in an unstable or serious condition.

The gastroenterologist also might be able to bill for a prolonged care service in addition to the daily E/M service if the combined time of the visits exceeds CPTs recommended time for subsequent hospital care visits by more than 30 minutes. For example, a gastroenterologist visits an acutely ill patient twice in one day and spends a total of 75 minutes with the patient. The suggested time for 99233 is 35 minutes, which means the internist spent an additional 40 minutes with the patient and may be able to bill a prolonged care service in addition to the subsequent hospital care visit, depending on the nature of the service.

Reimbursement for Indirect Prolonged Services

There are two prolonged service codes that can be billed with inpatient E/M service codes. Direct or face-to-face patient contact is reported with 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour). Code 99357 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; each additional 30 minutes) is used to report 30-minute increments beyond the first hour of direct prolonged service.

Prolonged physician service without direct (face-to-face) patient contact is reported with 99358 (prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals, and/or the patient/family]; first hour). Code 99359 (prolonged evaluation and management service before and/or after direct [face-to-face] patient care; each additional 30 minutes) is used to report 30-minute increments beyond the first hour of indirect prolonged service.

Although many Medicare carriers reimburse for direct prolonged service, Medicare has a national policy of not covering indirect prolonged services. Therefore, it is important to distinguish between the two types of service, a task that is made more difficult because neither Medicare nor CPT has clearly defined either service. If the gastroenterologist is in the room with the patient and directly managing the patients care by performing a physical examination or reviewing test results, that would be considered face-to-face contact, Brink says. Also if the family is gathered in the patients room and the gastroenterologist is discussing patient care issues with them, that could also be considered face-to-face.

However, if the gastroenterologist is talking with the family in the hospital lounge or the gastroenterologists office, those are considered indirect prolonged services, Brink continues. Any review of lab results or documentation, as well as phone calls made from the gastro-enterologists office, would be considered indirect services. And reviewing records by the patients bedside, but not actively managing the patients care, would be considered indirect prolonged care because the gastroenterologist didnt have to be with the patient to do that.

Although Medicare does not reimburse for indirect prolonged care services, some private payers may, according to Brink. Gastroenterologists should check with their payers to see if this is a covered service.