Wiki inpatient coding

[VHARDY]

My doctors see a lot of our patients in the hospital and they are challenging how detailed their note needs to be for billing the inpatient codes (99231-99233)

they are looking to use time spent with the patient as the primary source for picking a code.

anyone have any suggestions

 

[teresabug]

they can only use them based on time spent when 50% or more of the time is spent counseling the patient/family member/caregiver and/or for coordination of care with other providers. (see the page in your CPT right before the 99201 series starts.) This all must be documented in detail in the chart. Otherwise, the providers need to document a cc, HPI, ROS and PE and MDM just like any other E/M. Show them the documentation requirements in your CPT book. Good luck!

 

[MnTwins29]

Interval history and exam

they can only use them based on time spent when 50% or more of the time is spent counseling the patient/family member/caregiver and/or for coordination of care with other providers. (see the page in your CPT right before the 99201 series starts.) This all must be documented in detail in the chart. Otherwise, the providers need to document a cc, HPI, ROS and PE and MDM just like any other E/M. Show them the documentation requirements in your CPT book. Good luck!

For the subsequent visits of 99231 to 99233, only the interval history and exam are required, not complete. That means documenation of what has taken place with the patient since the last time the physician saw the patient. Yes, you would still need HPI - "feels good" would even count as a HPI element for example - and an exam (i.e. MD listens to heart - cardiovascular exam) - but only the changes from the last visit are needed, not the entire history and exam again.

 

[AmandaW]

MnTwins, Assessment and Plan also?

 

[MnTwins29]

MnTwins, Assessment and Plan also?

These should still be documented as well - the assessment would be how the patient's conditions are responding to the treatment (i.e. CHF- improving) and what would be the next steps (i.e. d/c IV Lasix, CXR in AM, etc.) That would not be considered "interval" - it is what the patient's condition is at the time of the visit and what course the physician will take to treat them - like any other visit in any other setting.