Neurology & Pain Management Coding Alert

Subsequent hospital care ranks among the top ten codes neurologists report to Medicare. But if you don't know how to distinguish the different interval history levels for 99231-99233, you could be setting yourself up to lose money and become a bulls-eye for auditors.

According to CMS, the OIG has noted problems with certain procedure codes for the past several years. Codes 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity) and 99233 ( . . . a detailed interval history; a detailed examination; medical decision making of high complexity) have come under the microscope of many payers, who may question the medical necessity of a 99231 ( . . . problem focused interval history; problem focused examination; medical decision making that is straightforward or of low complexity) encounter. Let our experts show you how to get on your way to proper coding with these interval history insights.

Inaccurate reporting of E/M services can under-compensate your neurologist if his services required more work and risk than what you bill, says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver. Additionally, she says, reporting a single E/M service level, especially if always the lowest level, can raise a "red flag" for payers and potentially increase your risk of documentation review.

"Education with providers is key," says Marianne Wink, RHIT, CPC, ACS-EM of the University of Rochester Medical Center, New York. If you consistently see low level codes and documentation that appears inadequate, the best course of action is to educate providers on the importance of good quality clinical documentation, she says.

Remember: Inadequate clinical information in a note is a disservice to a patient and his continued care. Inadequate documentation also results in revenue loss for a physician if you have to report a lower code. Check out the examples below to help select the best code.

All three subsequent hospital care codes in the CPT manual include an "interval history" as one of the three possible components used to determine correct reporting.

Remember: You choose subsequent hospital care codes based on two of three key components: interval history, exam and medical decision making. Because subsequent care codes are one of the few places you-ll find the "interval history" component (instead of the usual "history"), you need to be sure you understand exactly what to look for to choose the proper code.

Definition: Interval history refers to any change in the patient's history since the last history was taken. CPT instructs that all levels of subsequent hospital care include reviewing the medical record and reviewing the results of any diagnostic studies and changes in the patient's status since the physician's last assessment.

Learn About HPI Before Choosing 99231

Code 99231 requires a problem focused interval history. This should include a brief history of present illness (HPI), or one to three elements, says Hammer.

Example: "Mrs. Jones continues to have the right retro-orbital headache with radiation to the occipital region (location)," Hammer offers as a for-instance. "It has decreased to 4/10 (severity) with the IM triptan (modifying factor)." Documentation such as this qualifies as a 99231.

Code 99232 requires an expanded problem focused interval history. This should include a brief HPI (one to three elements) and problem pertinent review of systems (ROS) or an inquiry about the system directly related to the problem(s) identified in HPI, says Hammer.

Example: "Mr. Smith admitted yesterday with severe headache," Hammer says as an example. "Mr. Smith continues to have an occipital headache with radiation to the frontal region (location). His headache has decreased to 2/10 (severity) but is aggravated to 6/10 pain with sitting or standing (context). Mr. Smith denies any scalp paresthesia (nervous system)."

Code 99233 requires a detailed interval history. This should include an extended HPI, or four or more elements, and extended ROS (inquiry about the system directly related to problem[s] identified in HPI and a limited number of additional systems, meaning the patient's positive responses and pertinent negatives for two to nine systems), says Hammer.

Example: "Miss Brown admitted yesterday with severe headache," Hammer says in this example. "Miss Brown continues to have an intermittent (timing) 8/10 (severity) stabbing (quality) left retro-orbital headache (location). She notes a left ptosis (associated signs and symptoms) when her headaches occur. Since her admission, her headache typically has lasted 20 minutes (duration) and then resolves. The headache reoccurs approximately every two hours (timing). Miss Brown confirms nausea but no vomiting (gastrointestinal) with her headache. She denies any paresthesias (neurologic), muscle weakness (musculoskeletal), photophobia (eye) or phonophobia (ears, nose, mouth, throat)."

99231-99233 note: "Both the 1995 and 1997 Medicare Documentation Guidelines indicate it is not necessary that providers record information about the past, family and social history (PFSH) element," Hammer adds. (See http://www.cms.hhs.gov/MLNEDWebGuide/25_EMDOC.asp)

There are dangers to always reporting a low-level (99231) code when higher level codes better match the documentation. "Over- and undercoding, and -trends- of coding are a compliance risk," says Wink. "If a practice is undercoding they are losing revenue and not adhering to the coding guidelines." Furthermore, if you report 99231 for all of your subsequent hospital care services, you may be costing your practice more than money -- you could be marking yourself for an audit.