Neurosurgery Coding Alert

Answer 3 questions to strengthen your documentation

Are you worried that your surgeon is downcoding subsequent-care claims, but you don't know what do? Use our experts' answers as a guide for documenting subsequent-care E/M components, body systems and service levels.

The bottom line: Underdocumenting can result in undercoding, which in a year could cost the surgeon
thousands of dollars.

For example, suppose your surgeon believes his documentation won't support a higher-level subsequent-care code, and therefore he always uses 99231. Because 99231 pays about $20 less than 99232, downcoding these claims 10 times in a month could cost your practice $2,400 per year, coding experts say.

Question 1: Did the Surgeon Specify Two of the Three E/M Components? To avoid underreporting and underpayment for subsequent-care claims, make sure your surgeon's documentation assigns two of the key components to the following daily subsequent-care codes for a patient's evaluation and management:

99231 - ... problem-focused interval history, problem-focused exam, straightforward or low complexity medical decision-making
99232 - ... expanded problem-focused interval history, expanded problem-focused exam, moderatecomplexity medical decision-making
99233 - ... detailed interval history, detailed exam, high-complexity medical decision-making.

Remember: The key components are the history, the exam and medical decision-making (MDM), says Brett Baker, third-party payment specialist for the American College of Physicians in Washington, D.C. 

"The extent to which a physician performs history, exam, and MDM determines the level of service that is selected for a subsequent hospital care visit," Baker says. 

For instance, if the physician performs a subsequentcare visit on a recent diskectomy patient with a new complaint of neck pain and accurately documents an expanded problem-focused history and moderate-complexity medical decision-making, you may report 99232. 

Helpful Tip: You should consider medical decisionmaking the most important E/M component to satisfy because it best supports medical necessity, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Question 2: Did the Surgeon Report Two to Seven Body Systems?

The surgeon undertakes a subsequent hospital visit with an elderly patient admitted for acute subarachnoid hemorrhage. In this case, the surgeon must examine and document a detailed exam of at least two (and up to seven) body systems to report the visit using 99233.

The body systems the surgeon may examine include: constitutional eyes     ears, nose, mouth and throat

cardiovascular

respiratory

gastrointestinal

genitourinary

musculoskeletal

integumentary (skin and/or breast)

neurological

psychiatric

endocrine

hematologic/lymphatic

allergic/immunologic.
Question 3: How Can We Tell Whether Our 99231 Claims Are Accurate? If your neurosurgery practice repeatedly reports the same subsequent hospital care code, you should perform a chart review to ensure you're accurately coding the visits. 

"Take a random sampling of charts where you reported [...]