Pulmonology Coding Alert

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 [...]