Advanced Search

Pulmonology Coding Alert

Taking Subsequent Care for Granted? Know Your Documentation

Published on Tue Jul 01, 2003

Documentation: One word says it all when it comes to receiving pay for subsequent hospital care. For your pulmonologist to receive proper reimbursement, he or she should know the basics of proper documentation for subsequent hospital care services. Supplying too much or too little information could mean reduced or denied compensation.
 
Subsequent hospital care services include recording a patient history, ordering and reviewing diagnostic studies, and evaluating any change in the patients status, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. You should assign the following subsequent care codes per day for a patients evaluation and management:

 99231 ... problem focused interval history; problem focused exam; straightforward or low-complexity decision-making

 99232 ... expanded problem focused interval history; expanded problem focused exam; moderate-complexity decision-making

 99233 ... detailed interval history; detailed exam; high-complexity medical decision-making
 
To avoid underdocumenting, physicians should be as specific as possible with two of the three components, such as diagnostic studies and patient status, says Catherine Brink, CMM, CPC, president of Health Care Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J. For example, a pulmonologist lists 99232 but reports only that the patient is stable and has no complaints. Then why is the patient in the hospital? Brink asks. And questions like that could lead an auditor to downcode your physicians work to a 99231.

Report Two to Seven Body Systems
 
When your pulmonologist reports a detailed examination of a patient with pneumonia, he or she must examine and document at least two to seven 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. Pulmonologists must document information in the affected system, which is usually the respiratory system, in detail. Your physician should use phrases such as Chest clear for auscultation and palpation and Normal symmetry, expansion and effort of the chest in his or her reports. Avoid nondetailed descriptions of the affected site, such as Chest normal, Brink says.

Know the Service Levels
 
To help your pulmonologist better understand the service levels, Brink offers these steps:
 
 Present him or her with internal and external audits. These will show which codes were rejected, and thus the physician will have a better idea of how not to document subsequent care.
 
 Review the CMS documentation guidelines with the physician so that he or she will understand what constitutes a level-one, -two or -three standard of care. Sometimes doctors mistakenly assume that if they write enough notes Medicare or private carriers will pay for a higher level of treatment.
 
 Review the charts to make sure the physician has written diagnoses for his or her patients.
 
Underdocumenting sometimes results in undercoding as well, Brink says, because it often translates into coding a lower E/M level. Also, when a doctor doesnt know the criteria for a 99232, for example, and worries that listing it without the proper documentation will land him or her in trouble, the physician could report a lower level to save face. Downcoding over the course of a year could cost the physician thousands of dollars.

Know the Levels of Service
 
To better understand documenting subsequent care, your physician should remember real-life examples of each service level, Callaway says. She offers the following guidelines:
 
Low-level decision: The pulmonologist assesses a single problem, while gradually reducing the patients treatment. Or your physician could encounter a patient who has improved enough to be discharged the next day. The documentation for treatment could include phrases such as Condition improved since yesterday and Discharge tomorrow, Callaway says.
 
Moderate-level decision: Here the patient has a whole new problem, and the treatment plan doesnt work as expected. The pulmonologist might decide, for example, to discontinue use of one medication and begin another or consider invasive diagnostics. Reporting such treatments will transmit into a well-documented note, Callaway says.
 
High-level decision: The patient has a severe exacerbation, progression of illness, or side effect during treatment. Consider a patient who is admitted for chronic bronchitis (491.1, Chronic bronchitis; mucopurulent), doesnt respond to medications, and then develops pneumonia (480.9, Viral pneumonia, unspecified).
 
Sometimes patients who require high-complexity decision-making might also need a more intensive monitoring that could qualify for a critical care code. For example, consider the following:
 
A patient has thoracic surgery (32601, Thoracoscopy, diagnostic [separate procedure]; lungs and pleural space, without biopsy) and now complains of increasing shortness of breath (786.05), sharp pleuritic pain (786.52), and cyanosis (782.5). X-rays (71010) and arterial blood gas confirm pneumothorax (512.0), so your pulmonologist decides to perform a thoracentesis (32002, Thoracentesis with insertion of tube with or without water seal [e.g., for pneumothorax] [separate procedure]). If the respiratory distress becomes respiratory failure (518.81), your pulmonologist may qualify to report critical care, instead of a 99233, if he or she spends a cumulative of 30 minutes in face-to-face contact with the patient while on the same floor or unit. The 30 minutes of E/M cannot include any procedure time that would be separately billable from critical care (e.g., chest tube drainage). 

Learn to Trim Your Documentation
 
Writing a too-detailed account of a subsequent care treatment is another mistake that could cost physicians. Your hand gets tired, and if youre handwriting a note, by the end of the day half of them are illegible, which means then that all of your work is useless, Callaway says. Typically, physicians arent required to provide extensive reports, as long as they cover the essentials of medical necessity and diagnosis.
 
If you tell your pulmonologist that he or she has to write in so much detail, Callaway says, the physician could feel that youre telling him or her how to practice medicine when that was never the way it should have been anyway. And writing a long history and documenting a complete examination doesnt necessarily justify a high level of service, because the physician still has to prove medical necessity for the care.
  
For example, the Medicare Carriers Manual states that the presenting problem and medical decision-making are the guiding factors in choosing a level of service. Medicare recognizes that patients should progress from a level three to a level one if they are getting better, Callaway says.
 
In fact, if the initial inpatient admission documentation includes conditions that have been ruled out and establishes a game plan for treatment, the physician reports only what he or she finds during treatment, she adds. Your physician should remember, though, that medical necessity should be evident in the documentation in the days assessment notes, Callaway says. Writing just pulmonary service doesnt work.

Other Articles in this issue of

Pulmonology Coding Alert

View All