Pulmonology Coding Alert

Reader Questions:

Iron out 99233 Documentation Rules

Published on Fri Mar 05, 2021

Question: In your last issue, you listed the biggest errors that CMS found among Part B claims, and one of them involved subsequent hospital visits. We have a lot of problems in this area, and we’re trying to work with our pulmonologists to fix them. One problem involves one doctor who only reports 99233 and says it’s because every patient takes at least 35 minutes. But his documentation does not support that time with patients, so we aren’t sure what to do. How should we handle this?

Michigan Subscriber

Answer: When your physicians report 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: detailed interval history; A detailed examination; Medical decision making of high complexity … 35 minutes are spent at the bedside and on the patient’s hospital floor or unit) based on time, the documentation must not only reflect how much time spent, but also what it was spent on — and it should be spent on medically necessary issues, not talking about things like the weather or the latest baseball games. Additionally, more than 50 percent of the time must be spent counseling/coordinating care, the guidelines indicate. This differs from the new rules for office/outpatient time-based coding, so keep this in mind when using time to select your inpatient codes.

For example, the documentation might say “Patient seen and examined, read labs, and conferred with the hospitalist regarding the patient’s eosinophilic asthma attack. Talked to the patient about triggers, history, and how she can mitigate thee issues upon discharge. We worked together on establishing a plan of care that will incorporate trigger avoidance, inhalant medications, and nebulizer adherence. We also discussed how she can mitigate triggers at work, where she suspects the air ducts are not cleaned frequently, contributing to her asthma. We will talk again tomorrow, at which point she may be ready for discharge if stable. Total visit time 35 minutes. More than 50 percent spent counseling on issues referenced above.”

Check your physician’s existing 99233 documentation and show them the sample documentation so they can see the difference between how they’re documenting now and what they’ll need before they can justify reporting this high-level code.

Of course, if the history, exam, and medical decision making supports 99233 on their own, you don’t need the time documentation, since the subsequent inpatient E/M codes allow you to select either time or the key components when choosing a code.