Practice Management Alert

...but check with your insurer before settling on an E/M level

Billers that are reporting subsequent hospital care services must get the proper level of service on the claim. But it is not always easy to tell the differences among level-one, -two and -three subsequent hospital care, because documentation guidelines for these services vary by region and carrier.
 
Use This Key When Considering Care Level While there is no answer key for exactly what constitutes a level-one, -two or -three subsequent hospital care service, you should consider this chart when deciding on evaluation and management levels, says Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI, a billing company in Stoneham, Mass:

- If the patient is stable, recovering or improving, this is likely a 99231 service (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem-focused interval history; a problem- focused examination; medical decision-making that is straightforward or of low complexity).

- If the patient is responding inadequately to therapy or has developed a minor complication, you-ll use 99232 (... an expanded problem-focused interval history; an expanded problem-focused examination; medical decision-making of moderate complexity).

- If the patient is unstable or has developed a significant complication/new problem, these issues typically warrant 99233 service (... a detailed interval history; a detailed examination; and medical decision-making of high complexity). Caveat: These are not hard and fast rules--merely guidelines--to steer you toward the proper subsequent hospital care code. 

No matter what service level you choose, be sure your documentation proves medical necessity and explains clearly what the physician did during the subsequent hospital care encounter.