Wiki Billing/coding for hospital visits

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lindam@caricures.com

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I work for a colon/rectal surgeon. He was called into a hospital case for a patient with a parastomal hernia with an abdominal abscess. I billed visit as 99223 for the initial visit. And 99222 and 99232 for subsequent visits. UHC asked for records. They are stating that the records don't support the codes. I have H&P, Meds, review of tests and imaging and a plan. Any suggestions? What might we be missing.
 
There are many possibilities here. Below are your most likely culprits:
1) Some carriers will only pay ONE physician (the admitting) for the initial visit codes. All other physicians should be using subsequent, even for the first time seeing the patient.
2) You indicate subsequent was billed with 99222. That is an initial, not subsequent code.
3) The records do not support (in the carrier's eyes) the LEVEL of service billed. 99223 for example requires 2 of 3 for a high level problem, extensive data, and high risk. The carrier may view the documentation supports high problem, moderate data, and moderate risk so 99223 is not supported.

For issues 1 or 2, you would need to submit a corrected claim.
For issue 3 above, if after I review the records, I see the level supported, I would appeal and specify the level of each for problem, data and risk. If I cannot support the level in the records, I submit a corrected claim based on the accurate level. Remember, it's not the level provided, it's the level DOCUMENTED.
Good luck!
 
Oops. I already new I used the Initial code x2 and I fixed it. Looking at her hospital record, it looks like she might have been seen by a general surgeon prior to calling in the colon/rectal surgeon. I attached the consultation report. Any insight would be appreciated.
 

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I do not see this documentation as a level 3 inpatient (99223 or 99233). Patient has an abscess that has gotten larger over the last several weeks, but is afebrile, normal vitals, no distress. Don't see how you could get to high problem. Similarly, I am not seeing extensive data nor high risk. Level each of the 3 elements, and assign an inpatient visit accordingly.
 
csperoni said:
I do not see this documentation as a level 3 inpatient (99223 or 99233). Patient has an abscess that has gotten larger over the last several weeks, but is afebrile, normal vitals, no distress. Don't see how you could get to high problem. Similarly, I am not seeing extensive data nor high risk. Level each of the 3 elements, and assign an inpatient visit accordingly.
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Thanks for your input. I appreciate it. I will tell the provider to do better documentation :)
 
csperoni said:
I do not see this documentation as a level 3 inpatient (99223 or 99233). Patient has an abscess that has gotten larger over the last several weeks, but is afebrile, normal vitals, no distress. Don't see how you could get to high problem. Similarly, I am not seeing extensive data nor high risk. Level each of the 3 elements, and assign an inpatient visit accordingly.
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Would you be able to point me to a good source for coding these hospital visits? A worksheet or check list, anything that would help me get them right the first time. Thank you
 
lindam@caricures.com said:
Would you be able to point me to a good source for coding these hospital visits? A worksheet or check list, anything that would help me get them right the first time. Thank you
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Check with your local Medicare MAC for their copies of E&M worksheets. Read the criteria in your CPT book (make sure you have a current copy). Attend any AAPC Chapter meeting that you can find that discusses E&M coding/auditing. Look into NAMAS (National Alliance of Auditing Specialists). They are the industry experts in E&M auditing.
E&M coding is a specialty in and of itself, and commercial payers are all over this by running comparative billing reports and refusing to pay when the service isn't supported by documentation. What we're taught in the CPC exam course is not enough to do this at an expert level. Hope this helps.
 
Pam Warren said:
Check with your local Medicare MAC for their copies of E&M worksheets. Read the criteria in your CPT book (make sure you have a current copy). Attend any AAPC Chapter meeting that you can find that discusses E&M coding/auditing. Look into NAMAS (National Alliance of Auditing Specialists). They are the industry experts in E&M auditing.
E&M coding is a specialty in and of itself, and commercial payers are all over this by running comparative billing reports and refusing to pay when the service isn't supported by documentation. What we're taught in the CPC exam course is not enough to do this at an expert level. Hope this helps.
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Thank you. I am basically untrained, moved to this position in a small practice that used to use a billing company but moved it in house. I ask alot of questions.
 
I agree with @Pam Warren. Both AAPC and NAMAS have a ton of useful (and often completely free) information and resources. I personally find AMA's E&M Guideline to be an excellent resource. I have even quoted it to auditors when there is a difference of opinion.
E&M coding comes down to leveling the problem, data, and risk (or time). Once you can level those 3 elements, the overall level is clear. Good luck!
 
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