Neurology & Pain Management Coding Alert

There are some "shorthand" cues neurologists can use to help prepare effective documentation and help you choose the proper subsequent hospital care code.

As a starting point for physician education, coding experts suggest these basic guidelines for the three subsequent hospital care levels:

- 99231 -- Patient is stable, recovering or improving.

- 99232 -- Patient is responding inadequately to therapy, has developed a minor complication, or a new complaint or abnormal test result from a presentation.

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

While the documentation (history, exam, complexity and maybe time) will ultimately drive the supported service level, these guidelines help illustrate the differences in terms more familiar to neurologists. Make sure they understand the importance of their documentation so you can submit accurate claims. Solid documentation must support these levels of service.

Can you go beyond level three? If level three is inadequate for the severity of the complication, consider critical care if the patient's condition and physician's time spent support the code selection.

Remember, the code you choose must be based on the documentation of the visit's complexity. Avoid relying on generalizations about the patient's situation to select the subsequent hospital care code.