General Surgery Coding Alert

Subsequent Hospital Care:

Think 99231 Is the Only Option? Think Again

Published on Sat Sep 13, 2003

4 tips could keep your practice from losing more than $2,400

If you report 99231 for all of your subsequent hospital care services, you may be costing your practice more than money. You could be raising a red flag to payers or marking yourself for an audit.

According to CMS data, general surgeons report 99231 more often than any other subsequent hospital care code. This indicates that either most subsequent hospital visits are low-level services or surgeons routinely undercode for inpatient care. But as long as your documentation warrants it, you should report higher-level subsequent hospital care.

Because carriers usually bundle hospital care into postsurgical visits, many general surgeons aren't familiar with the documentation guidelines associated with subsequent hospital care for nonsurgical situations. If you pick up the patient's care after another physician - such as a patient's primary-care physician - admits the patient to the hospital, you should report the 99231-99233 code range.

Use the following four tips to ensure you're properly assigning these codes.

1. Learn the Coding Levels

You may believe that reviewing documentation is the first step to determine whether you can increase your inpatient coding levels, but that's actually the second step. If you don't know what constitutes each service level, reviewing the documentation won't help. So educate your practice regarding what CMS requires for each care level.

Here are basic guidelines for the three subsequent hospital care levels as a starting point for physician education, according to coding experts:

99231 - Patient is stable, recovering or improving.

99232 - Patient is responding inadequately to therapy or has developed a minor complication.

99233 - Patient is unstable or has developed a significant complication or a significant new problem.

If your practice routinely reports 99231 for all subsequent hospital care services, tell your physicians that this might raise red flags with your payer, coding experts say. For example, a carrier may identify your practice for "poor quality of care" because you consistently report low-level codes. If you submit only 99231, the payer may interpret that as saying all hospital patients, regardless of their conditions, only receive a problem-focused history and exam. This can indicate to managed-care plans that your physicians never take a complete history and never perform comprehensive exams.

"This may also indicate the same to Medicare because they keep profiles on every physician handling Medicare patients," says Judy Richardson, RN, MSA, CCS-P, senior consultant at Hill & Associates, a coding and compliance consulting firm based in Wilmington, N.C. "In addition, although Medicare originally started examining providers who were consistently billing the higher levels of service, it decided a few years ago to also examine providers billing the lower levels."

2. Use Medical Decision-Making to Choose a Level

Of the three E/M components - history, exam and medical decision-making (MDM) - you only have to document two to use one of the subsequent care codes, according to CPT.

Most physicians find that they can best fulfill the documentation requirements with the exam and MDM components when dealing with subsequent hospital visits (because the admitting physician already recorded the patient's history).

If the general surgeon performs high-complexity MDM but only a problem-focused history and exam, you have problem-focused documentation. You would code this type of visit using 99231, regardless of the patient's case complexity.

But remember that the patient's condition contributes to the MDM level. For example, a total abdominal hysterectomy with no associated risk factors requires moderately complex MDM (99232), whereas an appendectomy for a young girl with cystic fibrosis often requires high-level MDM (99233). But if the surgeon does not record the relevant information, the coder cannot support assigning a code for the care level that the doctor may feel he deserves, coding experts say.

3. Add Up Your Documentation

Unfortunately, many general surgeons are unaware that virtually everything they do involving a patient can contribute to the documentation. For example, merely looking at a patient's appearance and assessing his or her general appearance counts as one element of the service's examination portion. When documenting subsequent hospital care, remember to include additional observations, coding experts say, such as:

Is the patient's condition stable?

Is the condition either improving or worsening?

Have any new problems developed?

For example, if a hospitalized diabetic patient's diagnosis includes high blood pressure, the surgeon should document whether it worsens or improves. Documenting blood pressure and its resistance to change may support a higher-level code because of the greater MDM complexity required to manage it.

You should also consider such factors as lab values, ultrasound readings and x-ray films because you can use this information to support your MDM level. Most patients are sickest when first admitted, requiring a more complex diagnosis, examination and MDM - thus supporting a higher-level code. As the patient's condition improves, the level of subsequent-visit coding will probably decrease because the physician need no longer perform a detailed exam or more complex MDM.

Coding can fluctuate, however, among the three levels during the course of a hospital stay. If, for example, a patient's condition worsens or if new problems or conditions arise during the hospital stay, the treating physician will likely perform more examinations and make potentially complex medical decisions. Therefore, surgeons unfortunately can't live by any hard and fast rules for selecting low subsequent care levels.

"We usually have a mixture of preterm labor, pregnancy-induced hypertension, etc., that would never be at the 99231 level or they would probably be discharged," says Penny Schraufnagel, a medical practice office manager in Boise, Idaho. "More common is for us to use the 99232 for the daily charge or 99233 if the patient is having acute complications."

"Remember, however, that if you mention that the patient will be discharged either the day of the visit or the next morning, convincing a payer that anything other than 99231 is appropriate will be very difficult," Richardson says.

4. Review the Charts to Identify Problems

If your practice routinely reports the same code over and over, you should perform a chart review. Take a random chart sampling in which you reported 99231. On each file you should determine the history, exam and MDM levels and determine whether it meets the 99232 or 99233 requirements.

If the physicians fail to see the importance of such a review, you should place the number of visits they undercoded into a graphic format to show them how much money they left on the table. Because 99231 pays about $20 less than 99232, downcoding these claims just 10 times a month could cost your practice $2,400 per year. "Add to that the number of providers in the practice plus the number of hospital visits, and this could be a very substantial amount on a yearly basis," Richardson says.