Ob-Gyn Coding Alert

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, receive only 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. "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 has already recorded the patient's history).
 
If the ob-gyn 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 patient who develops an infection following a previous surgery may require moderately complex MDM (99232), and a multiparity delivery requires moderately complex MDM (99232), but a multiparity delivery with numerous fetuses often requires high-level MDM (99233). If the ob-gyn does not record the relevant information, however, the coder cannot support assigning a code for the care level that the doctor may feel he deserves, coding experts point out.

3. Add Up Your Documentation

 Unfortunately, many ob-gyns are unaware that virtually everything they do involving a patient can contribute to the documentation. For example, merely assessing a patient's 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:
 
 

For example, if a hospitalized diabetic patient's diagnosis includes high blood pressure, the ob-gyn 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 and ultrasound readings 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 probably will decrease because the physician no longer must 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, ob-gyns 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 or delivered," says Penny Schraufnagel, office manager for Ob-Gyn Center PA in Boise, Idaho. "More common is for us to use the 99232 for the daily charge or 99233 if she 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 a 99231 pays approximately $20 less than a 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.