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Orthopedic Coding Alert

Avoid Undercoding Subsequent Hospital Care

Published on Tue Apr 01, 2003

If your practice repeatedly reports 99231 for all of your subsequent hospital care services, this may not only cost your practice money: It could send a red flag to payers or mark you for an audit.

According to CMS data, orthopedists report 99231 more often than any other subsequent hospital care code. This indicates that either most subsequent hospital visits are low-level services or orthopedists routinely undercode for inpatient care. As long as your documentation warrants it, however, you should feel confident in coding higher-level subsequent hospital care.

Because carriers usually bundle hospital care into orthopedic surgeons' postsurgical visits, many orthopedists aren't familiar with the documentation guidelines associated with subsequent hospital care. If you pick up the patient's care after another physician such as a patient's primary-care physician admits the patient to the hospital, you should report the 99231-99233 code range.

If your practice routinely reports 99231 for all of its subsequent hospital care services, tell your physicians that this might raise red flags with your payer. "This may not necessarily happen with Medicare, as there wouldn't be any program dollars for them to capture," says Jean Acevedo, LHRM, CPC, CHC, senior consultant at Acevedo Consulting Inc., a national coding and compliance consulting firm based in Delray Beach, Fla. "However, I recently audited a practice that an HMO flagged for 'poor quality of care'due to a consistent pattern of low-level codes.

"Think about what all 99231s might mean: All hospital patients, regardless of the patient's condition, only receive a problem-focused history and exam because that is what 99231 tells the payer you have provided," Acevedo says. "This can indicate to managed-care plans that your physicians never take a complete history and never perform comprehensive exams."

Learn Coding Levels,Then Review Charts

Most practices believe that documentation review is the first step to determine whether they can increase their inpatient coding levels, but that's actually the second step. If you don't know what constitutes each level of service, reviewing the documentation won't help you. So you should first educate your practice on what CMS requires for each level of care.

(See "Documentation Is Key to Selecting Accurate Codes" in article 4 for a list of CMS'documentation guidelines and orthopedic examples of the three subsequent hospital care codes.)

Acevedo offers the following basic guidelines for the three subsequent hospital care levels as a good starting point for physician education:

  • 99231 Patient is stable, recovering or improving
  • 99232 Patient is responding inadequately to therapy or has developed a minor complication
  • 99233 Patient is unstable or has developed a significant complication or a significant new problem.

    Choosing a Level Is a Hard Process

    Of the three E/M components history, exam and medical decision-making you must fully document only two in a patient's chart to justify use of each code, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.

    Most physicians find that they can best fulfill these requirements by documenting the exam and medical decision-making components because they are dealing with subsequent hospital visits (and therefore the admitting physician already recorded the patient's history).

    If you perform high-complexity medical decision-making but only a problem-focused history and exam, you have problem-focused documentation, Acevedo says. "You would code this type of visit using 99231, regardless of the actual complexity of the patient's case."

    Moreover, the patient's condition contributes to the level of medical decision-making. For example, joint replacements with no associated risk factors require moderately complex medical decision-making, whereas vertebral or skull fractures often require high-level medical decision-making. If the orthopedist does not record the relevant information, however, the coder cannot support assigning a code for the level of care that the doctor may feel he deserves.

    Listing the Diagnosis Is Only the Beginning

    Unfortunately, many orthopedists are unaware that virtually everything they do involving a patient can contribute to the documentation. For example, merely looking at a patient's appearance and assessing his or her general appearance counts as one element of the examination portion of the service.

    When documenting subsequent hospital care, the orthopedist should not merely list the diagnosis. Remember to include additional observations, such as:

  • Is the patient's condition stable?
  • Is the condition either improving or worsening?
  • Have any new problems developed?

    For example, if a hospitalized diabetic patient's diagnosis includes a foot ulcer, the orthopedist should document whether the ulcer worsens or improves. Documenting an ulcer resistant to healing generally supports a higher-level code because of the greater complexity of medical decision-making required to manage it.

    Practices should also consider such factors as lab values, x-ray readings and EEGs because you can use this information to support your level of medical decision-making. Most patients are sickest when first admitted, requiring a more complex diagnosis, examination and medical decision-making thus supporting a higher-level code. As the patient's condition improves, the level of subsequent visit coding will probably decrease because the physician must no longer perform a detailed exam or more complex medical decision-making.

    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 orthopedist will likely perform more examinations and make medical decisions of varying complexity. Therefore, orthopedists unfortunately can't live by any hard and fast rules concerning selecting low levels of service for subsequent care.

    Chart Reviews Can Identify Problems

    "If your practice routinely reports the same code over and over, you should perform a chart review," Jandroep says. "Take a random sampling of charts where you reported 99231, and on each file you should determine the history, exam and medical decision-making levels and determine whether they meet the requirements for a 99232 or 99233."

    If the physicians fail to see the importance of such a review, you should place the number of visits they undercoded into a graphical format to show them how much money they left on the table. Because a 99231 pays about $20 less than a 99232, downcoding these claims just 10 times a month could cost your practice $2,400 per year.

    Note: You can reach consultant Jean Acevedo, LHRM, CPC, CHC, by e-mail at jacevedo@ acevedoconsulting.com.

     

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