Pulmonology Coding Alert

Dont take subsequent hospital care for granted supplying too much or too little information could translate into reduced or denied compensation. Test yourself below to see if you know the basics of proper documentation.
 
1. What services are included in subsequent hospital care?
 
Patient history, review or order of diagnostic studies, and evaluation of any change in the patients status, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. Your pulmonologist must provide as much specificity as possible with two of three services, says Catherine Brink, CMM, CPC, president of Health Care Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J.
 
2. True or false? For a detailed examination, of a patient with pneumonia, for example, your pulmo-nologist must examine and document at least two to seven body systems.
 
True: He or she should examine two of the following body systems: constitutional, eyes, ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (skin and/or breast); neurological; psychiatric; endocrine; and hematologic/lymphatic, and allergic/immunologic, Brink says. And your pulmonologist must document in detail the affected system, which is usually the respiratory system.
 
3. To ensure Medicare pays, is it wise to include as much information as possible in the subsequent care report?
 
No. Putting too much detail in your report is a mistake that could cost physicians. As long as your pulmonologist covers the essentials of medical necessity and diagnosis, he or she isnt required to provide an extensive report. Providing a long history and documenting a complete examination doesnt necessarily justify a high level of service the pulmonologist still has to prove medical necessity.
 
4. True or false? Underdocumentation of subsequent care doesnt correlate with undercoding.
 
False: If your pulmonologist underdocuments and has performed more of an E/M service than he or she documented, this often translates into coding a lower E/M level, Brink says. For example, your pulmonologist is unfamiliar with 99232 (... expanded problem focused interval history; expanded problem focused exam; moderate-complexity decision making), and he or she fears legal trouble if he or she uses the incorrect code. So, the physician reports a lower code than the standard of care provided and in a year, downcoding could cost the pulmonologist thousands of dollars.