Pulmonology Coding Alert

How to think outside the 99231 box If you learn subsequent hospital care's service levels, review the medical charts, and supply appropriate E/M documentation, you can report higher-level codes - and earn thousands in reimbursement.

Pulmonologists report 99231 more than any other subsequent hospital care code (99232-99233), according to CMS data. Therefore, pulmonologists either perform primarily low-level subsequent hospital visits or routinely undercode the care.

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, says Jean Acevedo, LHRM, CPC, CHC, senior consultant at Acevedo Consulting Inc., a national coding and compliance consulting firm based in Delray Beach, Fla.

What this means: If you're reporting 99231 (straightforward or low-complexity care) for all visits, Medicare and private payers may think the patient is well enough to leave the hospital. Therefore, insurers may deny facility payments for the total number of hospital days, regardless whether the carriers paid the physician. 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. You can use the following basic guidelines for the three levels of subsequent hospital care as a good starting point for physician education, Acevedo says: 

 99231 -- ... problem-focused interval history; problem-focused examination; 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 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. Save Thousands With Chart Reviews
 
If your pulmonology practice repeatedly reports the same subsequent hospital care code, you should perform a chart review to ensure you're accurately coding the visits, coding experts say.

"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," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.

When physicians fail to see the importance of such a review, you should place the number of visits they undercoded into graph form to [...]