Pediatric Coding Alert

Question: I am having an issue with one of our physicians who wants to report almost all of his hospital inpatient subsequent visit services as 99233. His rationale is that colleagues have told him that you can automat­ically report 99233 when the patient suffers from co-morbidities, or has a certain diagnosis. How can I make him understand that this is not correct coding without offending him?

Alaska Subscriber

Answer: Your physician is making dangerous assumptions about patient conditions and E/M levels.

While it’s true that a subsequent visit might result in a 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity…) service, no diagnosis ever warrants an automatic E/M level, regardless of the diagnosis code(s).

The physician must code each E/M according to the parameters of the descriptors; for 99233, he must perform two of three key components, and prove that he satisfied the components in the notes. Keep in mind that the nature of the presenting problem (NOPP) is the overriding factor in determining the level that you should document » and code. If he’s been automatically coding 99233 for a long time, the practice might have erroneously overcoded on some subsequent hospital care E/Ms. It’s nearly impossible that a physician would only use 99233, and never report 99231 (… a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity…) or 99232 (… an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity…).

Certainly, patients will require 99233 services from the physician at times — but not because of the condition. Rather, it’s the physician’s actions, spelled out in the documentation, that should lead you to your choice of service level.

In fact, Medicare and most payers expect to see hospital E/M levels drop to level two and level one as the patient improves. Payers do not expect your otolaryngologist to provide level-three hospital service and then discharge the patient shortly thereafter. Stable patients in an inpatient facility mostly require level-one subsequent visits, unless there are extenuating circumstances. As patients become more and more stable, they move from down from level three to an eventual discharge.

Someone — the coding director, another physician, etc. — has to relay this message to your physician before payers start asking questions. If a payer notices that all of a physician’s subsequent hospital inpatient services are 99233, you can bet it’s going to raise eyebrows. Payers expect various utilization curves for each family of codes, and reporting 99233 for each subsequent inpatient will demonstrate your physician as an outlier.