Otolaryngology Coding Alert

Remember: Subsequent inpatient care is reported on a per-day basis.

When your otolaryngologist performs rounds in the hospital, take note of whether patients were improving or getting worse — these factors could make a difference in your code choice.

That was the word from Yoshiko White-Dimes of Palmetto GBA during the Part B MAC’s June 25 webinar, “Subsequent Hospital Visits Review Webinar.”

Check out six of the most essential insights that White-Dimes shared during the presentation.

1. You Must Fulfill 2 of the 3 Components

When it comes to reporting the following subsequent hospital care codes, keep in mind that you must meet two of the three components, using the 1995 or 1997 EM guidelines to justify any particular code:

• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of the 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit)
• 99232 (… An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/ or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit)
• 99233 (… A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit)

“When looking at the subsequent hospital care overview, the key components we’re looking for here are the history, examination, and medical decision making,” White-Dimes said. “And as we all know, when billing for subsequent hospital care, there must be two of the three components, and they must be fully documented in order to bill.”

2. You’ll Report Subsequent Hospital Care Per Day

It’s very important to remember that you should only be reporting subsequent inpatient care once daily, White-Dimes noted.

“Subsequent hospital care codes may be reported only once per day by the same physician or physician of the same specialty from the same group practice,” she said. “Two different physicians may bill concurrently for subsequent hospital care, provided that those physicians are from different specialties, and that they are treating different diagnoses.”

A single provider or more than one physician from the same group practice cannot bill more than one subsequent hospital visit code in a calendar day, she added. “It is counted as one provider, one visit.”

In addition, she said, all levels of subsequent hospital care include a record review, as well as a review of any diagnostic results, and changes in the patient status since the last assessment by the physician.

3. Double-Check Your Documentation

It might seem obvious to hear a reminder that your documentation must be perfect to justify your code selections — but despite most people knowing about this requirement, the MACs still see scores of errors among the subsequent hospital care codes, White-Dimes said.

“Code 99231 usually requires documentation to support the fact that the patient is stable, recovering, or improving,” she said. “Code 99232 usually requires documentation noting that the patient is responding inadequately to therapy, or the patient has developed a minor complication. Those minor complications might include careful monitoring of comorbid conditions requiring continuous active management.”

If you’re reporting 99233, your documentation “should support that the patient is now unstable or the patient may have a significant new problem, or they may have experienced a complication,” she said.

4. Understand What the Interval History Requires

All of the codes in the 99231-99233 range require documentation of an interval history, and you should make sure your history is thorough, White-Dimes said. “In order to receive credit for an interval history, that provider must document the status of the patient from the last encounter, and there can be a simple statement like ‘no complaint,’ ‘no shortness of breath,’ ‘complaints of chest pain,’ or ‘the patient is doing well,’” she said.

5. Avoid ‘Cloning’

Even if you see the patient a few days in a row and you don’t have changes to report, you can’t just copy and paste your previous notes into a new day’s record. You should always update the record with each visit’s details, White-Dimes said.

“Don’t keep submitting the same code for each subsequent visit, regardless of the patient’s health,” she said. “Any red flags that you see, any signs of deterioration, anything that the patient is saying is different today should be reflected in the documentation, and in turn, that should be reflected in the coding.”

6. Don’t Resubmit If Claims Are Denied

“For all claims previously billed and denied by medical review, do not resubmit the claims,” White-Dimes said. “If you disagree with the decision from our medical review department, you must submit the appropriate documentation with a completed redetermination request form to the appeals department.”

In addition, she said, if the documentation indicates that both a nonphysician practitioner and a physician performed the service, and the claim is billed under the physician’s NPI, the billing physician must sign the record. “Additionally, the documentation must include a statement that the billing provider had face-to-face contact with the patient and performed a substantial portion of the E/M visit.”

If the visit occurs in a teaching environment, review the documentation to ensure that the billing provider has provided a teaching annotation and signature, she added.