Pulmonology Coding Alert

You can avoid their mistakes by following a few quick tips.

Seeing patients in the hospital can present myriad challenges, from making the right diagnosis to creating the most accurate documentation. But one challenge that appears to be falling through the cracks is accurately coding subsequent hospital visits.

That's the word from a recent Medicare report, which states that pulmonologists logged some of the highest improper payment rates for subsequent hospital care. With 12.7 percent of the claims reviewed in this category classified as improper payments, pulmonologists were responsible for over $72 million in improper payments in this code set alone.

The government's CERT auditors found other problems beyond the subsequent visit claims. For example, providers treating pulmonary disease logged an overall Part B error rate of 11.3 percent, representing $169 million in Medicare claims.

The backstory: CMS issued its "2017 Medicare Fee-for-Service Supplemental Improper Payment Data" in December as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the biggest errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found a 10.2 percent improper payment rate among Part B claims during 2017, with the majority of those being classified as overpayments to providers.

Avoid These Problems With A Few Simple Tips

Keep in mind that although CMS identified 12.7 percent of pulmonologists' subsequent hospital visits as improper payments, that doesn't mean that these were all overpayments. Some may have been upcoded, some may have had no documentation, while others may have been undercoded or had insufficient documentation.

No matter what your most pressing subsequent hospital code issues are, following five quick steps can help you get your coding in line.

Step 1: Get to Know the Coding Levels

Although many consultants will advise practices to review all physician documentation to evaluate whether the right level is being billed, that's not necessarily the first step you should follow. If you and your pulmonary practitioners don't know what constitutes each service level, reviewing the documentation won't help.

Therefore, you should educate your clinicians regarding what CMS and CPT®  require for each care level.

You can use the following basic guidelines for the three subsequent hospital care levels as a good starting point for physician education. The following codes apply to subsequent hospital care, along with the requirements for each code:

• 99231 - ... A problem focused interval history; A problem focused examination; medical decision making that is straightforward or of low complexity ...
• 99232 - ... An expanded problem focused interval history; An expanded problem focused examination; medical decision making of moderate complexity ...
• 99233 - ... A detailed interval history; A detailed examination; medical decision making of high complexity ...

Remember: You need two of the three key E/M components (history, exam, and/or medical decision-making) to report subsequent hospital care services. So if your doctor records a problem-focused interval history but an expanded problem-focused exam and moderate complexity medical decision-making (MDM), you can report 99232 since both the exam and MDM meet the requirements for this code.

Remember, medical necessity is the overarching factor for code selection, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. "For example, some people may choose 99233 based on a detailed history and a detailed exam, despite a low or moderate complexity MDM," she says. "However, there should be a medical need to obtain a detailed history, especially if the patient is stable without any acute or altering events and approaching discharge."

Step 2: Warn Doctors of 'Playing It Safe' Dangers

If your practice routinely reports 99231 for all subsequent hospital care services, tell your physicians that this might raise red flags with your payer. Contrary to popular belief, coding 99231 across the board will not exempt you from a government audit.

For example, a payer may identify your practice for "poor quality of care" because you consistently report low-level codes. If you submit only 99231, the payer may interpret that as saying all hospital patients, regardless of their conditions, receive only a problem-focused history and exam. This can indicate to insurers that your physicians never take a detailed history or exam.

Step 3: Review Charts to Identify Problems

If your practice routinely reports the same code over and over, or if you simply suspect that you aren't coding subsequent hospital visits accurately, you should perform a chart review. Take a random chart sampling, and on each file, you should determine the history, exam, and medical decision-making (MDM) levels, then determine which code the documentation supports.

You may be surprised what you find. "Patient feeling OK today" does not even support 99231 - but some coders have reported seeing documentation as sparse as this in physicians' notes during subsequent visits.

Tactic:  If the physicians fail to see the importance of such a review, you should place the number of visits they undercoded into a graphic format to show them how much money they left on the table.

Resource: To read the full CERT document, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2017-Medicare-FFS-Improper-Payment.pdf.