Oncology & Hematology Coding Alert

Why you may be losing $2,400 a year on 99231 If you're reporting 99231 for all of your oncologist's subsequent hospital care services, you could be costing your practice thousands in deserved reimbursement. To earn your keep, you should learn CPT's subsequent care service levels, review the medical charts, and supply appropriate E/M documentation.

Oncologists report 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) more than any other subsequent hospital care code (99232-99233), according to CMS data. When your physician reports 99231 for every subsequent hospital care service, inform your physician that this coding method could lead to an audit. Payers may think your physician performs only a problem-focused history and exam on all patients. Because 99231 pays about $20 less than 99232, downcoding these claims just 10 times a month could cost your practice $2,400 per year. 1. Learn Coding Levels,Then Review Charts To determine whether your practice can increase your inpatient coding levels, make sure you know what constitutes each service level before you review the documentation, coding experts say. You can use the following basic guidelines for the three subsequent hospital care levels as a good starting point for physician education. 99231 -- ... problem-focused interval history; problem-focused exam; straightforward or low-complexity medical decision-making. Patient is stable, recovering or improving. 99232 -- ... expanded problem-focused interval history; expanded problem-focused exam; moderate-complexity medical decision-making. Patient responds inadequately to therapy or has developed a minor complication. 99233 -- ... detailed interval history; detailed exam; high-complexity medical decision-making. Patient is unstable or has developed a significant complication or a significant new problem. Remember: You need two of the three key E/M components (history, exam, and medical decision-making) to report subsequent hospital care services. To best support medical necessity, you should document medical decision-making as one of the two components. 2. Chart Reviews If your oncology practice routinely bills the same subsequent hospital care code, you should perform a chart review to ensure you're accurately coding the visits, coding experts say.  For instance, you take a random sampling of charts in which you reported 99231. You review each file to determine whether the history, exam and medical decision-making levels meet the requirements for 99232 or 99233, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.

Another possible coding problem is when the physician reports 99233 one day, 99231 for the same patient the following day, and then returns to a 99233 charge the day after, says Kelly Reibman, CPC, a billing representative for an oncology practice in Easton, Penn.

Make sure the documentation explains why the patient's condition necessitated different coding [...]