Carol Pohlig

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For all the differences highlighted in my April and May columns studying the 1995 and 1997 documentation guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA), decision making remains consistent in both.

Physician documentation addresses the complexity of the patient’s condition in terms of the number of diagnoses and/or treatment options, the amount and/or complexity of data ordered/reviewed, and the risk of complications/morbidity/mortality. The “diagnoses” and “data” categories follow a point system (see Table 1, below) determined by local Medicare contractors, whereas the “risk” category utilizes a universal table to define medical and/or procedural risks for the patient. The final result of complexity is classified as straightforward, low, moderate, or high.

Code THIS Case

A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity. Examination is conducted to rule out deep vein thrombosis (DVT) vs. cellulitis. Testing confirms DVT, and the patient begins anticoagulation therapy (lovenox and coumadin). To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring. Explicit patient instruction is attempted in preparation for discharge. What level of complexity should the hospitalist report?

The Solution

Upon admission, the complexity of the patient’s condition is considered high, given the nature of the presenting problem. The physician receives “extensive” credit for developing the plan of care involving differential diagnoses identified in the progress note; increased diagnostic and cognitive efforts were made in arriving at the correct diagnosis. Additionally, the anticoagulation therapy places the patient at increased (“high”) risk for bleeding, requiring intensive monitoring for toxicity.

The complexity of the patient’s condition may not be as high on a subsequent hospital day. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive. Therefore, without new or additional factors, the overall complexity of decision making may be more appropriately categorized as moderate or low.—CP

A complete and accurate description of the patient’s condition should be conveyed through the plan of care. While acuity and severity may be inferred by a physician’s colleagues from particular pieces of information included in the record (e.g., critical lab values), the importance of this information may be lost on auditors and medical record reviewers. This article will assist in explaining the categories of medical decision making, as well as provide documentation tips to best represent patient complexity.

Diagnoses, Care Options

The plan of care outlines problems the physician personally manages and those that affect their management options, even if another physician directly oversees the problem. For example, the hospitalist may primarily manage a patient’s diabetes while the nephrologist manages renal insufficiency. Since the renal insufficiency may affect the hospitalist’s plan for diabetic management, the hospitalist receives credit for the documented renal insufficiency diagnosis and hospitalist-related care plan.

Physicians should address all problems in the documentation for each encounter regardless of any changes to the treatment plan. Credit is provided for each problem that has an associated plan, even if the plan states “continue same treatment.” Additional credit is provided when the treatment to be “continued” is referenced somewhere in the progress note (e.g., in the history).

The amount of credit varies depending upon the problem type. An established problem, defined as having a care plan established by the physician or someone from the same group practice during the current hospitalization, is considered less complex than an undiagnosed new problem for which a prognosis cannot be determined. Severity of the problem affects the weight of complexity. A stable, improving problem is not as complex as a progressing problem.

When documenting diagnoses/treatment options:

Identify all problems managed or addressed during each encounter;

Identify problems as stable or progressing, when appropriate;

Indicate differential diagnoses when the problem remains undefined; and

Indicate the management/treatment option(s) for each problem.

When documentation indicates a continuation of current management options (e.g., “continue meds”), be sure the management options to be continued are noted somewhere in the progress note for that encounter (e.g., medication list).

TIP OF THE MONTH: Audit Tools

Evaluation and management services are monitored closely by Medicare. To avoid overpayment for underdocumented services, prepayment documentation requests are in place for certain inpatient services, including 99233, 99232, 99255, and 99239.

Although the focus of medical record documentation should not be billing or payment-related issues, it is difficult to escape this reality. Knowing how each payer reviews physician documentation is essential in understanding which factors are necessary to include in the medical record. Some payers use a standard audit tool for auditing consistency and post them on their Web site for providers to incorporate in their internal auditing efforts.

A pair of examples are available at these links:

www.trailblazerhealth.com/Publications/Job%20Aid/coding%20pocket%20reference.pdf; and

www.highmarkmedicareservices.com/partb/reference/pdf/scoresheets/8985.pdf.

The biggest difference between the two examples lies in medical decision making. Variations exist in crediting physicians for the number of diagnoses/treatment options and the amount/complexity of data. Though they may vary slightly, there may a significant effect on the billing outcome. Familiarize yourself with the rules applicable to your geographical area. Peruse insurer Web sites for guidelines, policies, and frequently asked questions that can help improve documentation skills and justify billing levels.—CP

Data Ordered/Reviewed

“Data” order/review comes in many forms: pathology/laboratory testing, radiology, and medicine-based diagnostics. Although an intuitive part of medical practice, the data section of the progress note is often underdocumented by physicians. Pertinent orders or results may be noted in the visit record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note.

When documenting amount and/or complexity of data:

Specify tests ordered and rationale in the physician’s progress note or make an entry that refers to another auditor-accessible location for ordered tests and studies;

Test review may be documented by including a brief entry in the progress note (e.g., “decreased Hgb” or “CXR shows NAD”), or by dating and initialing the report;

Physicians receive credit for reviewing old records or obtaining history from someone other than the patient, when necessary, as long as a summary of the review or discussion is documented in the medical record; and

Indicate when images, tracings, or specimens are “personally reviewed” by the physician.

Discussion of unexpected or contradictory test results with the performing physician should be summarized in the medical record.

Risks of Complication

Risk is viewed in light of the patient’s presenting problem, diagnostic procedures ordered, and management options selected.

Risk is graded as minimal, low, moderate, and high with corresponding items that help to differentiate each level (see Table 2, right). The single highest item in any given risk category determines the risk level.

Chronic conditions and invasive procedures expose the patient to more risk than acute, uncomplicated illnesses or non-invasive procedures, respectively. As in the diagnoses/treatment options category, a stable or improving problem poses less risk than a progressing problem. Medication risk varies with the type and degree of potential adverse effects associated with each medication.

When documenting risk:

Indicate status of all problems in the plan of care; identify them as stable, worsening, exacerbating (mild or severe), etc.;

Document all diagnostic procedures being considered;

Identify surgical risk factors involving co-morbid conditions, when appropriate; and

Associate the labs ordered to monitor for toxicity with the corresponding. medication (e.g., “Continue coumadin, monitor PT/INR”). A patient maintains the same level of risk for a given medication whether the dosage is increased, decreased, or continued without change.

Determine Complexity

To determine the final complexity of medical decision making, two of three categories must be met. For example, if a physician satisfies the requirements for “multiple” diagnoses/treatment options, “minimal” data, and “high” risk, the physician achieves moderate complexity decision-making.

Remember that decision-making is just one of three components of evaluation and management services, along with history and exam.

Determining the final visit level (e.g., 9922x) depends upon each of these three key components for initial hospital care and consultations, and two key components for subsequent hospital care. However, medical decision making always should drive visit level selection as it is the best representation of medical necessity for the service involved.

Contributory Factors

In addition to the three categories of medical decision making, a payer (e.g., TrailblazerHealth) may consider contributory factors when determining patient complexity and selecting visit levels.

For example, the nature of the presenting problem may play a role when reviewing claims for subsequent hospital care codes (99231-99233). Found in the code descriptors of the CPT manual, problems are identified as:

99231: Stable, recovering or improving;

99232: Responding inadequately to therapy or developed a minor complication; and

99233: Unstable or has developed a significant complication or a significant new problem.

Although this is not a general requirement, it represents a locally established standard for reviewing claims for medical necessity. It should not be used exclusively to determine the visit level.

Be sure to query your payer’s policy via written communication or Web site posting (e.g., www.trailblazerhealth.com/Publications/Job%20Aid/medical%20necessity.pdf) for guidance on how payers review documentation. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

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The Solution

Diagnoses, Care Options

When documenting diagnoses/treatment options:

Identify all problems managed or addressed during each encounter;

Identify problems as stable or progressing, when appropriate;

Indicate differential diagnoses when the problem remains undefined; and

Indicate the management/treatment option(s) for each problem.

TIP OF THE MONTH: Audit Tools

A pair of examples are available at these links:

www.trailblazerhealth.com/Publications/Job%20Aid/coding%20pocket%20reference.pdf; and

www.highmarkmedicareservices.com/partb/reference/pdf/scoresheets/8985.pdf.

Data Ordered/Reviewed

When documenting amount and/or complexity of data:

Specify tests ordered and rationale in the physician’s progress note or make an entry that refers to another auditor-accessible location for ordered tests and studies;

Test review may be documented by including a brief entry in the progress note (e.g., “decreased Hgb” or “CXR shows NAD”), or by dating and initialing the report;

Physicians receive credit for reviewing old records or obtaining history from someone other than the patient, when necessary, as long as a summary of the review or discussion is documented in the medical record; and

Indicate when images, tracings, or specimens are “personally reviewed” by the physician.

Discussion of unexpected or contradictory test results with the performing physician should be summarized in the medical record.

Risks of Complication

Risk is viewed in light of the patient’s presenting problem, diagnostic procedures ordered, and management options selected.

When documenting risk:

Indicate status of all problems in the plan of care; identify them as stable, worsening, exacerbating (mild or severe), etc.;

Document all diagnostic procedures being considered;

Identify surgical risk factors involving co-morbid conditions, when appropriate; and

Associate the labs ordered to monitor for toxicity with the corresponding. medication (e.g., “Continue coumadin, monitor PT/INR”). A patient maintains the same level of risk for a given medication whether the dosage is increased, decreased, or continued without change.

Determine Complexity

Remember that decision-making is just one of three components of evaluation and management services, along with history and exam.

Contributory Factors

In addition to the three categories of medical decision making, a payer (e.g., TrailblazerHealth) may consider contributory factors when determining patient complexity and selecting visit levels.

99231: Stable, recovering or improving;

99232: Responding inadequately to therapy or developed a minor complication; and

99233: Unstable or has developed a significant complication or a significant new problem.

Although this is not a general requirement, it represents a locally established standard for reviewing claims for medical necessity. It should not be used exclusively to determine the visit level.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

Code THIS Case

The Solution

Diagnoses, Care Options

When documenting diagnoses/treatment options:

Identify all problems managed or addressed during each encounter;

Identify problems as stable or progressing, when appropriate;

Indicate differential diagnoses when the problem remains undefined; and

Indicate the management/treatment option(s) for each problem.

TIP OF THE MONTH: Audit Tools

A pair of examples are available at these links:

www.trailblazerhealth.com/Publications/Job%20Aid/coding%20pocket%20reference.pdf; and

www.highmarkmedicareservices.com/partb/reference/pdf/scoresheets/8985.pdf.

Data Ordered/Reviewed

When documenting amount and/or complexity of data:

Specify tests ordered and rationale in the physician’s progress note or make an entry that refers to another auditor-accessible location for ordered tests and studies;

Test review may be documented by including a brief entry in the progress note (e.g., “decreased Hgb” or “CXR shows NAD”), or by dating and initialing the report;

Physicians receive credit for reviewing old records or obtaining history from someone other than the patient, when necessary, as long as a summary of the review or discussion is documented in the medical record; and

Indicate when images, tracings, or specimens are “personally reviewed” by the physician.

Discussion of unexpected or contradictory test results with the performing physician should be summarized in the medical record.

Risks of Complication

Risk is viewed in light of the patient’s presenting problem, diagnostic procedures ordered, and management options selected.

When documenting risk:

Indicate status of all problems in the plan of care; identify them as stable, worsening, exacerbating (mild or severe), etc.;

Document all diagnostic procedures being considered;

Identify surgical risk factors involving co-morbid conditions, when appropriate; and

Associate the labs ordered to monitor for toxicity with the corresponding. medication (e.g., “Continue coumadin, monitor PT/INR”). A patient maintains the same level of risk for a given medication whether the dosage is increased, decreased, or continued without change.

Determine Complexity

Remember that decision-making is just one of three components of evaluation and management services, along with history and exam.

Contributory Factors

In addition to the three categories of medical decision making, a payer (e.g., TrailblazerHealth) may consider contributory factors when determining patient complexity and selecting visit levels.

99231: Stable, recovering or improving;

99232: Responding inadequately to therapy or developed a minor complication; and

99233: Unstable or has developed a significant complication or a significant new problem.

Although this is not a general requirement, it represents a locally established standard for reviewing claims for medical necessity. It should not be used exclusively to determine the visit level.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

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Choose Your Exam Rules

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Choose Your Exam Rules

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Physicians only should perform patient examinations based upon the presenting problem and the standard of care. As mentioned in my previous column (April 2008, p. 21), the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) set forth two sets of documentation guidelines. The biggest difference between them is the exam component.

1995 Guidelines

The 1995 guidelines distinguish 10 body areas (head and face; neck; chest, breast, and axillae; abdomen; genitalia, groin, and buttocks; back and spine; right upper extremity; left upper extremity; right lower extremity; and left lower extremity) from 12 organ systems (constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; hematologic, lymphatic, and immunologic).

Further, these guidelines let physicians document their findings in any manner while adhering to some simple rules:

Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems; and

Elaborate on abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.

Physician Alert

On Feb. 22, CMS issued written clarification for discharge day management services. Many Medicare contractors, consultants, and educators had been instructing physicians to report discharge day management services (CPT 99238-99239) only when the physician provides a face-to-face encounter with the patient. CMS confirmed this in Transmittal 1460 (Change Request 5794).

Additionally, CMS clarified when discharge day management can be reported (www.cms.hhs.gov/transmittals/downloads/R1460CP.pdf). Effective April 1:

The discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner, even if the patient is discharged from the facility on a different calendar date; and

The date of the pronouncement shall reflect the calendar date of service on the day it was performed, even if the paperwork is delayed to a subsequent date.

This second clarification varies from previous instruction that only allowed the physician to report 99238 or 99239 on the last day of the inpatient stay. Now, the physician can perform the necessary components and report discharge day management (e.g., final face-to-face visit with the patient, approve and/or the patient’s discharge, provide additional patient instruction as necessary) on the day before the patient leaves the facility. If physician documentation on the day prior to discharge does not include a statement about the patient’s discharge, it would be more appropriate to report subsequent hospital care (99231-99233).—CP

1997 Guidelines

The 1997 guidelines comprise bulleted items—referred to as elements—that correspond to each organ system. Some elements specify numeric criterion that must be met to credit the physician for documentation of that element.

For example, the physician only receives credit for documentation of vital signs (an element of the constitutional system) when three measurements are referenced (e.g., blood pressure, heart rate, and respiratory rate). Documentation that does not include three measurements or only contains a single generalized comment (e.g., vital signs stable) cannot be credited to the physician in the 1997 guidelines—even though these same comments are credited when applying the 1995 guidelines.

This logic also applies to the lymphatic system. The physician must identify findings associated with at least two lymphatic areas examined (e.g., “no lymphadenopathy of the neck or axillae”).

Elements that do not contain numeric criterion but identify multiple components require documentation of at least one component. For example, one psychiatric element involves the assessment of the patient’s “mood and affect.” If the physician comments that the patient appears depressed but does not comment on a flat (or normal) affect, the physician still receives credit for this exam element.

Code This Case

Minimum requirements not met: Upon admission to the hospitalist service, a 76-year-old male presents with hyperglycemia related to uncontrolled diabetes mellitus. Even though the hospitalist performed a complete exam, documentation only reflects an expanded problem-focused exam. What visit level can the hospitalist report for the initial inpatient (admission) service?

The Solution

An expanded problem-focused exam does not satisfy the minimum requirements for initial hospital care (99221). While some reviewers would say this service is not reportable (non-billable) since the minimum requirements were not met, some Medicare contractors allow the physician to report the service as an unlisted evaluation and management service (99499).

An unlisted code can represent many services not represented by another CPT code—therefore, a formal description and fee do not exist for unlisted codes. When reporting the service as 99499, manually add a description (e.g., initial hospital care with an EPF exam”) in the appropriate comment box on the electronic claim form, as well as a fee for the service. Unlisted codes also prompt the payer to initially suspend or reject the claim, pending review of the documentation. When requested, send all physician documentation surrounding the initial admission service.—CP

Levels of Exam

There are four levels of exam, determined by the number of elements documented in the progress note (see Tables 1A and 1B, p. below).

As with the history component, the physician must meet the requirements for a particular level of exam before assigning it. The most problematic feature of the 1995 guidelines involves the “detailed” exam. Both the expanded problem-focused and detailed exams involve two to seven systems/areas, but the detailed exam requires an “extended” exam of the affected system/area related to the presenting problem. Questions surround the number of elements needed to qualify as an “extended” exam of the affected system/area.

Does “regular rate and rhythm; normal S1, S2; no jugular venous distention; no murmur, gallop, or rub; peripheral pulses intact; no edema noted” constitute an “extended” exam of the cardiovascular system, or should there be an additional comment regarding the abdominal aorta? This decision is left to the discretion of the local Medicare contractor and/or the medical reviewer.

Since no other CMS directive has been provided, documentation of the detailed exam continues to be inconsistent. More importantly, review and audit of the detailed exam remains arbitrary. Some Medicare contractors suggest using the 1997 requirements for the detailed exam, while others create their own definition and corresponding number of exam elements needed for documentation of the detailed exam. This issue exemplifies the ambiguity for which the 1995 guidelines often are criticized.

Meanwhile, the 1997 guidelines often are criticized as too specific. While this may help the medical reviewer/auditor, it hinders the physician. Physicians are frequently frustrated trying to remember the explicit comments and number of elements associated with a particular level of exam.

One solution is documentation templates. Physicians can use paper or electronic templates that incorporate cues and prompts for normal exam findings, incorporating adequate space to elaborate abnormal findings.

Remember the physician has the option of utilizing either the 1995 or 1997 guidelines, depending upon which set he perceives as easier to implement.

Additionally, auditors must review physician documentation using both the 1995 and 1997 guidelines, and apply the most favorable result to the final audit score.

Each type of evaluation and management service identifies a specific level of exam that must be documented in the medical record before the associated CPT code is submitted on a claim.

The most common visit categories provided by hospitalists and corresponding exam levels are outlined in Table 2 (above). Similar to the history component, other visit categories, such as critical care and discharge day management, do not have specified levels of exam or associated documentation requirements for physical exam elements. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

The 1997 Guidelines In Detail

Elements that physicians must document correspond to each organ system. Some elements specify numeric criterion that must be met to credit the physician for documentation of that element.

Constitutional

Measurement of any three of the following seven vital signs: sitting or standing blood pressure; supine blood pressure; pulse rate and regularity; respiration; temperature; height; and weight (may be measured and recorded by ancillary staff); and

General appearance of patient (development, nutrition, body habitus, deformities, attention to grooming).

Eyes

Inspection of conjunctivae and lids;

Examination of pupils and irises (reaction to light and accommodation, size and symmetry); and

Ophthalmoscopic examination of optic discs (size, C/D ratio, appearance) and posterior segments (vessel changes, exudates, hemorrhages).

Ears, Nose, Mouth, and Throat

External inspection of ears and nose (overall appearance, scars, lesions, masses);

Otoscopic examination of external auditory canals and tympanic membranes;

Assessment of hearing (whispered voice, finger rub, tuning fork);

Inspection of nasal mucosa, septum, and turbinates;

Inspection of lips, teeth and gums; and

Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx.

Neck

Examination of neck (masses, overall appearance, symmetry, tracheal position, crepitus); and

Examination of thyroid (enlargement, tenderness, mass).

Respiratory

Assessment of respiratory effort (intercostal retractions, use of accessory muscles, diaphragmatic movement);

Percussion of chest (dullness, flatness, hyperresonance);

Palpation of chest (tactile fremitus); and

Auscultation of lungs (breath sounds, adventitious sounds, rubs).

Cardiovascular

Palpation of heart (location, size, thrills);

Auscultation of heart with notation of abnormal sounds and murmurs; and

Examination of carotid arteries (pulse amplitude, bruits); abdominal aorta (size, bruits); femoral arteries (pulse amplitude, bruits); pedal pulses (pulse amplitude); and extremities for edema and/or varicosities.

Chest (Breasts)

Inspection of breasts (symmetry, nipple discharge); and

Palpation of breasts and axillae (masses or lumps, tenderness).

Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence of masses or tenderness;

Examination of liver and spleen;

Examination for presence or absence of hernia;

Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses; and

-Obtain stool sample for occult blood test when indicated.

Genitourinary

Male

Examination of the scrotal contents (hydrocele, spermatocele, tenderness of cord, testicular mass);

Examination of the penis; and

Digital rectal examination of prostate gland (size, symmetry, nodularity, tenderness).

Female

Pelvic examination (with or without specimen collection for smears and cultures), including:

Examination of external genitalia (general appearance, hair distribution, lesions) and vagina (general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele);

Examination of urethra (masses, tenderness, scarring);

Examination of bladder (fullness, masses, tenderness);

Cervix (general appearance, lesions, discharge);

Uterus (size, contour, position, mobility, tenderness, consistency, descent or support); and

Adnexa/parametria (masses, tenderness, organomegaly, nodularity).

Lymphatic

Palpation of lymph nodes in two or more areas:

Neck;

Axillae;

Groin; or

Other.

Musculoskeletal

Examination of gait and station;

Inspection and/or palpation of digits and nails (clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);

Examination of joints, bones and muscles of one or more of the following six areas: head and neck; spine, ribs and pelvis; right upper extremity; left upper extremity; right lower extremity; and left lower extremity. The examination of a given area includes:

Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;

Assessment of range of motion with notation of any pain, crepitation or contracture;

Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and

Assessment of muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

Skin

Inspection of skin and subcutaneous tissue (rashes, lesions, ulcers); and

Palpation of skin and subcutaneous tissue (induration, subcutaneous nodules, tightening).

Neurologic

Test cranial nerves with notation of any deficits;

Examination of deep tendon reflexes with notation of pathological reflexes (Babinski); and

Examination of sensation (by touch, pin, vibration, proprioception).

Psychiatric

Description of patient’s judgment and insight; and

Brief assessment of mental status including orientation to time, place, and person; recent and remote memory; and mood and affect (depression, anxiety, agitation).—CP

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1995 Guidelines

Further, these guidelines let physicians document their findings in any manner while adhering to some simple rules:

Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems; and

Elaborate on abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.

Physician Alert

Additionally, CMS clarified when discharge day management can be reported (www.cms.hhs.gov/transmittals/downloads/R1460CP.pdf). Effective April 1:

The discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner, even if the patient is discharged from the facility on a different calendar date; and

The date of the pronouncement shall reflect the calendar date of service on the day it was performed, even if the paperwork is delayed to a subsequent date.

1997 Guidelines

This logic also applies to the lymphatic system. The physician must identify findings associated with at least two lymphatic areas examined (e.g., “no lymphadenopathy of the neck or axillae”).

Code This Case

The Solution

Levels of Exam

There are four levels of exam, determined by the number of elements documented in the progress note (see Tables 1A and 1B, p. below).

Remember the physician has the option of utilizing either the 1995 or 1997 guidelines, depending upon which set he perceives as easier to implement.

Additionally, auditors must review physician documentation using both the 1995 and 1997 guidelines, and apply the most favorable result to the final audit score.

Each type of evaluation and management service identifies a specific level of exam that must be documented in the medical record before the associated CPT code is submitted on a claim.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

The 1997 Guidelines In Detail

Elements that physicians must document correspond to each organ system. Some elements specify numeric criterion that must be met to credit the physician for documentation of that element.

Constitutional

Measurement of any three of the following seven vital signs: sitting or standing blood pressure; supine blood pressure; pulse rate and regularity; respiration; temperature; height; and weight (may be measured and recorded by ancillary staff); and

General appearance of patient (development, nutrition, body habitus, deformities, attention to grooming).

Eyes

Inspection of conjunctivae and lids;

Examination of pupils and irises (reaction to light and accommodation, size and symmetry); and

Ophthalmoscopic examination of optic discs (size, C/D ratio, appearance) and posterior segments (vessel changes, exudates, hemorrhages).

Ears, Nose, Mouth, and Throat

External inspection of ears and nose (overall appearance, scars, lesions, masses);

Otoscopic examination of external auditory canals and tympanic membranes;

Assessment of hearing (whispered voice, finger rub, tuning fork);

Inspection of nasal mucosa, septum, and turbinates;

Inspection of lips, teeth and gums; and

Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx.

Neck

Examination of neck (masses, overall appearance, symmetry, tracheal position, crepitus); and

Examination of thyroid (enlargement, tenderness, mass).

Respiratory

Assessment of respiratory effort (intercostal retractions, use of accessory muscles, diaphragmatic movement);

Percussion of chest (dullness, flatness, hyperresonance);

Palpation of chest (tactile fremitus); and

Auscultation of lungs (breath sounds, adventitious sounds, rubs).

Cardiovascular

Palpation of heart (location, size, thrills);

Auscultation of heart with notation of abnormal sounds and murmurs; and

Examination of carotid arteries (pulse amplitude, bruits); abdominal aorta (size, bruits); femoral arteries (pulse amplitude, bruits); pedal pulses (pulse amplitude); and extremities for edema and/or varicosities.

Chest (Breasts)

Inspection of breasts (symmetry, nipple discharge); and

Palpation of breasts and axillae (masses or lumps, tenderness).

Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence of masses or tenderness;

Examination of liver and spleen;

Examination for presence or absence of hernia;

Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses; and

-Obtain stool sample for occult blood test when indicated.

Genitourinary

Male

Examination of the scrotal contents (hydrocele, spermatocele, tenderness of cord, testicular mass);

Examination of the penis; and

Digital rectal examination of prostate gland (size, symmetry, nodularity, tenderness).

Female

Pelvic examination (with or without specimen collection for smears and cultures), including:

Examination of external genitalia (general appearance, hair distribution, lesions) and vagina (general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele);

Examination of urethra (masses, tenderness, scarring);

Examination of bladder (fullness, masses, tenderness);

Cervix (general appearance, lesions, discharge);

Uterus (size, contour, position, mobility, tenderness, consistency, descent or support); and

Adnexa/parametria (masses, tenderness, organomegaly, nodularity).

Lymphatic

Palpation of lymph nodes in two or more areas:

Neck;

Axillae;

Groin; or

Other.

Musculoskeletal

Examination of gait and station;

Inspection and/or palpation of digits and nails (clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);

Examination of joints, bones and muscles of one or more of the following six areas: head and neck; spine, ribs and pelvis; right upper extremity; left upper extremity; right lower extremity; and left lower extremity. The examination of a given area includes:

Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;

Assessment of range of motion with notation of any pain, crepitation or contracture;

Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and

Assessment of muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

Skin

Inspection of skin and subcutaneous tissue (rashes, lesions, ulcers); and

Palpation of skin and subcutaneous tissue (induration, subcutaneous nodules, tightening).

Neurologic

Test cranial nerves with notation of any deficits;

Examination of deep tendon reflexes with notation of pathological reflexes (Babinski); and

Examination of sensation (by touch, pin, vibration, proprioception).

Psychiatric

Description of patient’s judgment and insight; and

Brief assessment of mental status including orientation to time, place, and person; recent and remote memory; and mood and affect (depression, anxiety, agitation).—CP

1995 Guidelines

Further, these guidelines let physicians document their findings in any manner while adhering to some simple rules:

Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems; and

Elaborate on abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.

Physician Alert

Additionally, CMS clarified when discharge day management can be reported (www.cms.hhs.gov/transmittals/downloads/R1460CP.pdf). Effective April 1:

The discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner, even if the patient is discharged from the facility on a different calendar date; and

The date of the pronouncement shall reflect the calendar date of service on the day it was performed, even if the paperwork is delayed to a subsequent date.

1997 Guidelines

This logic also applies to the lymphatic system. The physician must identify findings associated with at least two lymphatic areas examined (e.g., “no lymphadenopathy of the neck or axillae”).

Code This Case

The Solution

Levels of Exam

There are four levels of exam, determined by the number of elements documented in the progress note (see Tables 1A and 1B, p. below).

Remember the physician has the option of utilizing either the 1995 or 1997 guidelines, depending upon which set he perceives as easier to implement.

Additionally, auditors must review physician documentation using both the 1995 and 1997 guidelines, and apply the most favorable result to the final audit score.

Each type of evaluation and management service identifies a specific level of exam that must be documented in the medical record before the associated CPT code is submitted on a claim.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

The 1997 Guidelines In Detail

Elements that physicians must document correspond to each organ system. Some elements specify numeric criterion that must be met to credit the physician for documentation of that element.

Constitutional

Measurement of any three of the following seven vital signs: sitting or standing blood pressure; supine blood pressure; pulse rate and regularity; respiration; temperature; height; and weight (may be measured and recorded by ancillary staff); and

General appearance of patient (development, nutrition, body habitus, deformities, attention to grooming).

Eyes

Inspection of conjunctivae and lids;

Examination of pupils and irises (reaction to light and accommodation, size and symmetry); and

Ophthalmoscopic examination of optic discs (size, C/D ratio, appearance) and posterior segments (vessel changes, exudates, hemorrhages).

Ears, Nose, Mouth, and Throat

External inspection of ears and nose (overall appearance, scars, lesions, masses);

Otoscopic examination of external auditory canals and tympanic membranes;

Assessment of hearing (whispered voice, finger rub, tuning fork);

Inspection of nasal mucosa, septum, and turbinates;

Inspection of lips, teeth and gums; and

Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx.

Neck

Examination of neck (masses, overall appearance, symmetry, tracheal position, crepitus); and

Examination of thyroid (enlargement, tenderness, mass).

Respiratory

Assessment of respiratory effort (intercostal retractions, use of accessory muscles, diaphragmatic movement);

Percussion of chest (dullness, flatness, hyperresonance);

Palpation of chest (tactile fremitus); and

Auscultation of lungs (breath sounds, adventitious sounds, rubs).

Cardiovascular

Palpation of heart (location, size, thrills);

Auscultation of heart with notation of abnormal sounds and murmurs; and

Examination of carotid arteries (pulse amplitude, bruits); abdominal aorta (size, bruits); femoral arteries (pulse amplitude, bruits); pedal pulses (pulse amplitude); and extremities for edema and/or varicosities.

Chest (Breasts)

Inspection of breasts (symmetry, nipple discharge); and

Palpation of breasts and axillae (masses or lumps, tenderness).

Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence of masses or tenderness;

Examination of liver and spleen;

Examination for presence or absence of hernia;

Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses; and

-Obtain stool sample for occult blood test when indicated.

Genitourinary

Male

Examination of the scrotal contents (hydrocele, spermatocele, tenderness of cord, testicular mass);

Examination of the penis; and

Digital rectal examination of prostate gland (size, symmetry, nodularity, tenderness).

Female

Pelvic examination (with or without specimen collection for smears and cultures), including:

Examination of external genitalia (general appearance, hair distribution, lesions) and vagina (general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele);

Examination of urethra (masses, tenderness, scarring);

Examination of bladder (fullness, masses, tenderness);

Cervix (general appearance, lesions, discharge);

Uterus (size, contour, position, mobility, tenderness, consistency, descent or support); and

Adnexa/parametria (masses, tenderness, organomegaly, nodularity).

Lymphatic

Palpation of lymph nodes in two or more areas:

Neck;

Axillae;

Groin; or

Other.

Musculoskeletal

Examination of gait and station;

Inspection and/or palpation of digits and nails (clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);

Examination of joints, bones and muscles of one or more of the following six areas: head and neck; spine, ribs and pelvis; right upper extremity; left upper extremity; right lower extremity; and left lower extremity. The examination of a given area includes:

Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;

Assessment of range of motion with notation of any pain, crepitation or contracture;

Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and

Assessment of muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

Skin

Inspection of skin and subcutaneous tissue (rashes, lesions, ulcers); and

Palpation of skin and subcutaneous tissue (induration, subcutaneous nodules, tightening).

Neurologic

Test cranial nerves with notation of any deficits;

Examination of deep tendon reflexes with notation of pathological reflexes (Babinski); and

Examination of sensation (by touch, pin, vibration, proprioception).

Psychiatric

Description of patient’s judgment and insight; and

Brief assessment of mental status including orientation to time, place, and person; recent and remote memory; and mood and affect (depression, anxiety, agitation).—CP

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Documentation in the medical record serves many purposes: communication among healthcare professionals, evidence of patient care, and justification for provider claims.

Although these three aspects of documentation are intertwined, the first two prevent physicians from paying settlements involving malpractice allegations, while the last one assists in obtaining appropriate reimbursement for services rendered. This is the first of a three-part series that will focus on claim reporting and outline the documentation guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association (AMA).

1995, 1997 Guidelines

Two sets of documentation guidelines are in place, referred to as the 1995 and 1997 guidelines. Increased criticism of the ambiguity in the 1995 guidelines from auditors and providers inspired development of the 1997 guidelines.

While the 1997 guidelines were intended to create a more objective and unified approach to documentation, the level of specificity required brought criticism and frustration. But while the physician community balked, most auditors praised these efforts.

To satisfy all parties and allow physicians to document as they prefer, both sets of guidelines remain. Physicians can document according to either style, and auditors are obligated to review provider records against both sets of guidelines, selecting the final visit level with the set that best supports provider documentation.

Elements of History

Chief complaint (CC): The CC is the reason for the visit as stated in the patient’s own words. This must be present for each encounter, and should reference a specific condition or complaint (e.g., patient complains of abdominal pain).

History of present illness (HPI): This is a description of the present illness as it developed. It is typically formatted and documented with reference to location, quality, severity, timing, context, modifying factors, and associated signs/symptoms as related to the chief complaint. The HPI may be classified as brief (a comment on fewer than HPI elements) or extended (a comment on more than four HPI elements). Sample documentation of an extended HPI is: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”

The 1997 guidelines offer an alternate format for documenting the HPI. In contrast to the standard method above, the physician may list and status the patient’s chronic or inactive conditions. An extended HPI consists of the status of at least three chronic or inactive conditions (e.g., “Diabetes controlled by oral medication; extrinsic asthma without acute exacerbation in past six months; hypertension stable with pressures ranging from 130-140/80-90”). Failing to document the status negates the opportunity for the physician to receive HPI credit. Instead, he will receive credit for a past medical history.

TIP OF THE MONTH

The general principles of medical record documentation for evaluation and management (E/M) services are as follows:

The medical record should be complete and legible;

Documentation of each patient encounter should include at minimum: the reason for the visit, relevant history, physical exam findings and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the observer;

The rationale for ordering diagnostic and other ancillary services should be documented or easily inferred;

Past and present diagnoses should be available to the treating and/or consulting physician;

Appropriate health-risk factors should be identified;

Document patient progress, response to and changes in treatment, and revision of diagnosis; and

Documentation should support the CPT and ICD-9-CM codes reported for billing.

Some of these principles may be adjusted as reasonably necessary to account for the varying circumstances encountered by physicians when providing E/M services.—CP

The HPI should never be documented by ancillary staff (e.g., registered nurse, medical assistant, students). HPI might be documented by residents (e.g., residents, fellows, interns) or nonphysician providers (nurse practitioners and physician assistants) when utilizing the Teaching Physician Rules or Split-Shared Billing Rules, respectively (teaching Physician Rules and Split-Shared Billing Rules will be addressed in an upcoming issue).

Review of systems (ROS): This is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient:

Constitutional;

Eyes; ears, nose, mouth, throat;

Cardiovascular;

Respiratory;

Gastrointestinal;

Genitourinary;

Musculoskeletal;

Integumentary (including skin and/or breast);

Neurological;

Psychiatric;

Endocrine;

Hematologic/lymphatic; and

Allergic/immunologic.

The ROS may be classified as brief (a comment on one system), expanded (a comment on two to nine systems), or complete (a comment on more than 10 systems).

Documentation of a complete ROS (more than 10 systems) can occur in two ways:

The physician can individually document each system. For example: “No fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular); shortness of breath (respiratory); or belly pain (gastrointestinal); etc.”; or

The physician can document the positive findings and pertinent negative findings related to the chief complaint, along with a comment that “all other systems are negative.” This latter statement is not accepted by all local Medicare contractors.

Information involving the ROS can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented ROS in his progress note. Re-documentation of the ROS is not necessary unless a revision is required.

Past, family, and social history (PFSH): Documentation of PFSH involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. The PFSH can be classified as pertinent (a comment on one history) or complete (a comment in each of the three histories). Documentation that exemplifies a complete PFSH is: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s esophagus; no tobacco or alcohol use.”

As with ROS, the PFSH can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented PFSH in his progress note. Re-documentation of the PFSH is not necessary unless a revision is required. It is important to note that while documentation of the PFSH is required when billing higher level consultations (99254-99255) or initial inpatient care (99221-99223), it is not required when reporting subsequent hospital care services (99231-99233).

Levels of History

There are four levels of history, determined by the number of elements documented in the progress note (see Table 1, p. 21). The physician must meet all the requirements in a specific level of history before assigning it.

If all of the required elements in a given history level are not documented, the level assigned is that of the least documented element. For example, physician documentation may include four HPI elements and a complete PFSH, yet only eight ROS. The physician can only receive credit for a detailed history. If the physician submitted a claim for 99222 (initial hospital care requiring a comprehensive history, a comprehensive exam, and moderate-complexity decision making), documentation would not support the reported service due to the underdocumented ROS. Deficiencies in the ROS and family history are the most common physician documentation errors involving the history component.

A specific level of history is associated with each type of physician encounter, and must be documented accordingly (see Table 2, right). The most common visit categories provided by hospitalists that include documentation requirements for history are initial inpatient consultations, initial hospital care, subsequent hospital care, and initial observation care. Other visit categories, such as critical care and discharge day management, have neither associated levels of history nor documentation requirements for historical elements. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

CODE THESE CASES

Case 1 (deficient history): The hospitalist documents a problem-focused history (“no new events overnight”) after providing subsequent hospital care to a patient with uncontrolled diabetes mellitus, hypertension, status post hip repair. If documentation supports a detailed examination and medical decision making of high complexity, can the hospitalist appropriately report 99233 (subsequent hospital care requiring two of three key components: detailed history, detailed examination, high-complexity decision making)?

The Solution

Yes. Visit level selection is based upon three “key” components: history, exam, and medical decision-making. Some visit categories allow for visit level selection based on two of the three key components (e.g., subsequent hospital care) while others consider all three components (e.g., initial hospital care, inpatient consultations, and initial observation care). Although the “problem-focused” documentation involving the history component is insufficient for reporting 99233, visit-level selection for subsequent hospital care is based upon two key components. Since the hospitalist documented a detailed exam and high-complexity decision making, reporting 99233 is acceptable.

Case 2 (unable to obtain): Upon admission to the hospitalist service, an 82-year-old female presents with shortness of breath, dehydration, and confusion. The patient was transferred from her residence at a nursing facility without accompanying records. Limited information was obtained by the emergency medical technician, and the patient is an unreliable source. The available information is documented, but the level of history is only expanded problem-focused. Can the hospitalist receive additional credit for the history?

The Solution

Yes. The documentation guidelines specifically reference this situation. When the physician cannot elicit historical information from the patient, and no other source is available, the physician should document that he is “unable to obtain” the history and the circumstances surrounding this problem (e.g., patient confused, no caregiver present).

The hospitalist can receive “complete history” credit for his attempted efforts.—CP

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Documentation in the medical record serves many purposes: communication among healthcare professionals, evidence of patient care, and justification for provider claims.

1995, 1997 Guidelines

Elements of History

TIP OF THE MONTH

The general principles of medical record documentation for evaluation and management (E/M) services are as follows:

The medical record should be complete and legible;

Documentation of each patient encounter should include at minimum: the reason for the visit, relevant history, physical exam findings and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the observer;

The rationale for ordering diagnostic and other ancillary services should be documented or easily inferred;

Past and present diagnoses should be available to the treating and/or consulting physician;

Appropriate health-risk factors should be identified;

Document patient progress, response to and changes in treatment, and revision of diagnosis; and

Documentation should support the CPT and ICD-9-CM codes reported for billing.

Some of these principles may be adjusted as reasonably necessary to account for the varying circumstances encountered by physicians when providing E/M services.—CP

Review of systems (ROS): This is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient:

Constitutional;

Eyes; ears, nose, mouth, throat;

Cardiovascular;

Respiratory;

Gastrointestinal;

Genitourinary;

Musculoskeletal;

Integumentary (including skin and/or breast);

Neurological;

Psychiatric;

Endocrine;

Hematologic/lymphatic; and

Allergic/immunologic.

The ROS may be classified as brief (a comment on one system), expanded (a comment on two to nine systems), or complete (a comment on more than 10 systems).

Documentation of a complete ROS (more than 10 systems) can occur in two ways:

The physician can individually document each system. For example: “No fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular); shortness of breath (respiratory); or belly pain (gastrointestinal); etc.”; or

The physician can document the positive findings and pertinent negative findings related to the chief complaint, along with a comment that “all other systems are negative.” This latter statement is not accepted by all local Medicare contractors.

Levels of History

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

CODE THESE CASES

The Solution

The hospitalist can receive “complete history” credit for his attempted efforts.—CP

Documentation in the medical record serves many purposes: communication among healthcare professionals, evidence of patient care, and justification for provider claims.

1995, 1997 Guidelines

Elements of History

TIP OF THE MONTH

The general principles of medical record documentation for evaluation and management (E/M) services are as follows:

The medical record should be complete and legible;

Documentation of each patient encounter should include at minimum: the reason for the visit, relevant history, physical exam findings and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the observer;

The rationale for ordering diagnostic and other ancillary services should be documented or easily inferred;

Past and present diagnoses should be available to the treating and/or consulting physician;

Appropriate health-risk factors should be identified;

Document patient progress, response to and changes in treatment, and revision of diagnosis; and

Documentation should support the CPT and ICD-9-CM codes reported for billing.

Some of these principles may be adjusted as reasonably necessary to account for the varying circumstances encountered by physicians when providing E/M services.—CP

Review of systems (ROS): This is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient:

Constitutional;

Eyes; ears, nose, mouth, throat;

Cardiovascular;

Respiratory;

Gastrointestinal;

Genitourinary;

Musculoskeletal;

Integumentary (including skin and/or breast);

Neurological;

Psychiatric;

Endocrine;

Hematologic/lymphatic; and

Allergic/immunologic.

The ROS may be classified as brief (a comment on one system), expanded (a comment on two to nine systems), or complete (a comment on more than 10 systems).

Documentation of a complete ROS (more than 10 systems) can occur in two ways:

The physician can individually document each system. For example: “No fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular); shortness of breath (respiratory); or belly pain (gastrointestinal); etc.”; or

The physician can document the positive findings and pertinent negative findings related to the chief complaint, along with a comment that “all other systems are negative.” This latter statement is not accepted by all local Medicare contractors.

Levels of History

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

CODE THESE CASES

The Solution

The hospitalist can receive “complete history” credit for his attempted efforts.—CP

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Hospitalists often encounter patients who are or could become critically ill. The increased efforts while caring for these patients are best captured through critical-care service codes 99291 and 99292.

Although these codes yield higher reimbursement ($204.15 and $102.45, respectively, per national Medicare average payment), they are reported only under certain circumstances. The physician’s documentation must include enough detail to support critical-care claims: the patient’s condition, the nature of the physician’s care, and the time spent rendering care. Documentation of any other pertinent information is strongly encouraged because these services often come under payer scrutiny.

Condition and Care

A patient’s condition must meet the established criteria before the service qualifies as critical care. More specifically, the patient must have a critical illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.

The physician’s personal attention (i.e., care involving one critically ill patient at a time) is essential for rendering the highly complex decisions necessary to prevent the patient’s decline if left untreated. Given the seriousness of the patient’s condition, the physician is expected to focus only on the patient for whom critical-care time is reported.

Code of the Month

Critical Care Services

99291: Critical care, evaluation, and management of the critically ill or critically injured patient; first 30-74 minutes.

99292: Critical care, evaluation, and management of the critically ill or critically injured patient; each additional list 30 minutes separately in addition to code for primary service.

Code 99291 is used to report the first 30-74 minutes of critical care on a given date. It should be used only once per date even if the time spent by the physician is not continuous on that date. Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E/M code.

Code 99292 is used to report additional blocks of time, of up to 30 minutes each beyond the first 74 minutes.

Duration

Critical care is a time-based service. It constitutes the physician’s time spent providing direct care at the bedside and gathering and reviewing data on the patient’s unit or floor.

If the physician is not immediately available to the patient, the time associated with indirect care (e.g., reviewing data, calling the family from the office) is not counted in the overall critical-care service.

The physician keeps tracks of his/her total critical-care time throughout the day. A new period of critical-care time begins each calendar day. There is no prohibition against reporting multiple hours or days of critical care, as long as the patient’s condition prompts the service and documentation supports it.

Code 99291 represents the first “hour” of critical care, which physicians may report after accumulating the first 30 minutes of care. Alternately, physician management of the patient involving less than 30 minutes of critical-care time on a given day must be reported with the appropriate evaluation and management (E/M) code:

Initial inpatient service (99221-99223);

Subsequent hospital care (99231-99233); or

Inpatient consultation (99251-99255).

Once the physician achieves 75 minutes of critical-care time, he/she reports 99292 for the additional “30 minutes” of care beyond the first hour. Never report 99292 alone on the claim form. Code 99292 is considered an “add-on” code, which means it must be reported in addition to a primary code. Code 99291 is always the primary code (reported once per physician/group per day) for critical-care services. Code 99292 can be reported in multiple units per physician/group per day according to the number of minutes spent after the initial hour (see Table 1, p. 30).

Service Inclusions

Critical care involves highly complex decision making to manage the patient’s condition. This includes the physician’s performance and/or interpretation of labs, diagnostic studies, and procedures inherent in critical care.

Therefore, do not report the following services when billing 99291-99292:

Cardiac output measurements (93561, 93562);

Chest X-rays (71010, 71015, 71020);

Pulse oximetry (94760, 94761, 94762); and

Blood gases (multiple codes).

Further, don’t report interpretation of data stored in computers:

Electrocardiograms, blood pressures, hematologic data (99090);

Gastric intubation (43752, 91105);

Temporary transcutaneous pacing (92953);

Ventilation management (94002-94004, 94660, 94662); and

Vascular access procedures (36000, 36410, 36415, 36591, 36600).

Any other service or procedure provided by the physician can be billed in addition to 99291-99292.

Be sure not to add separately billable procedure time into the physician’s total critical-care time. A notation in the medical record should reflect this (e.g., time spent inserting a central line is not included in today’s critical-care time).

Location

Because a patient can become seriously ill in any setting, physicians often provide critical-care services in emergency departments (EDs) and on standard medical-surgical floors before the patient is transferred to the intensive care unit (ICU).

Bed location alone does not determine critical-care reporting. Patients assigned to an ICU might be critically ill or injured and meet the “condition” requirements for 99291-99292.

However, the care provided may not meet the remaining requirements. According to the American Medical Association’s Current Procedural Terminology 2008 (Professional Edition) and the Medicare Claims Processing Manual, payment can be made for critical-care services provided in any location as long as the care provided meets the definition of critical care. Services for a patient who is not critically ill and unstable but who happens to be receiving care in a critical-care, intensive-care, or other specialized-care unit are reported using subsequent hospital care codes 99231-99233 or hospital consultation codes 99251-99255. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

Code These Cases

Case 1 (family meetings): The hospitalist provides 45 minutes of critical care to a patient admitted with septicemia. The patient’s condition worsens despite multiple efforts, and the patient’s family arrives later in the day to discuss the patient’s condition. The discussion lasts an additional 30 minutes, and the decision regarding the patient’s do not resuscitate status is made. What service(s) should the hospitalist report?

The Solution

Family meeting time can be counted toward critical-care service time when:

The patient is unable or clinically incompetent to participate in discussions;

Time is spent on the unit/floor with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care;

The conversation bears directly on the management of the patient. Meetings that take place for grief counseling involving the patient’s family (90846, 90847, 90849) are not reported separately or included as part of the critical-care time.

This scenario meets the criteria for inclusion in critical-care time. A total of 75 minutes was spent for the day. The hospitalist can report one unit of 99291 and one unit of 99292.

Note: A common physician-reporting error for the scenario above involves reporting 99291 with a prolonged care (99356-99357) or subsequent hospital care codes (99231-99233). Prolonged care is reserved for use with initial hospital care (99221-99223), subsequent hospital care (99231-99233), and inpatient consultation codes (99251-99255).

Reporting subsequent hospital care codes for the family meeting is also erroneous since the patient had received critical care for the day. As per Medicare guidelines, both critical care and an E/M service can be paid (appending modifier 25 to the E/M: 99291, 99233-25), but only if the inpatient E/M service was furnished early in the day when the patient did not require critical care, yet required it later that same day. Documentation must support this situation because it will need to be sent to the insurer before payment is obtained. Once critical care is initiated, subsequent evaluations on the same day are counted toward critical-care time, as in this scenario.

Case 2 (multiple physicians): The hospitalist sees the patient upon admission to the ICU, spending and documenting 40 minutes of critical-care time. That evening, the covering physician (a hospitalist from the same group practice) renders 35 minutes of critical care. Can each hospitalist submit a claim for 99291?

The Solution

No. Only one physician per group practice (same specialty) can report 99291 per day. The additional time is captured with 99292. Because 99292 must be reported as an add-on code with 99291 (i.e., cannot be reported by itself on a claim), submit one claim representing the culmination of all critical-care services provided by the group for the day. Select one physician’s name (typically the physician who initiated critical care), and report one unit of 99291 with one unit of 99292 for the 75 minutes of critical care provided.

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Condition and Care

Code of the Month

Critical Care Services

99291: Critical care, evaluation, and management of the critically ill or critically injured patient; first 30-74 minutes.

99292: Critical care, evaluation, and management of the critically ill or critically injured patient; each additional list 30 minutes separately in addition to code for primary service.

Code 99292 is used to report additional blocks of time, of up to 30 minutes each beyond the first 74 minutes.

Duration

Critical care is a time-based service. It constitutes the physician’s time spent providing direct care at the bedside and gathering and reviewing data on the patient’s unit or floor.

Initial inpatient service (99221-99223);

Subsequent hospital care (99231-99233); or

Inpatient consultation (99251-99255).

Service Inclusions

Therefore, do not report the following services when billing 99291-99292:

Cardiac output measurements (93561, 93562);

Chest X-rays (71010, 71015, 71020);

Pulse oximetry (94760, 94761, 94762); and

Blood gases (multiple codes).

Further, don’t report interpretation of data stored in computers:

Electrocardiograms, blood pressures, hematologic data (99090);

Gastric intubation (43752, 91105);

Temporary transcutaneous pacing (92953);

Ventilation management (94002-94004, 94660, 94662); and

Vascular access procedures (36000, 36410, 36415, 36591, 36600).

Any other service or procedure provided by the physician can be billed in addition to 99291-99292.

Location

Bed location alone does not determine critical-care reporting. Patients assigned to an ICU might be critically ill or injured and meet the “condition” requirements for 99291-99292.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

Code These Cases

The Solution

Family meeting time can be counted toward critical-care service time when:

The patient is unable or clinically incompetent to participate in discussions;

Time is spent on the unit/floor with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care;

The conversation bears directly on the management of the patient. Meetings that take place for grief counseling involving the patient’s family (90846, 90847, 90849) are not reported separately or included as part of the critical-care time.

This scenario meets the criteria for inclusion in critical-care time. A total of 75 minutes was spent for the day. The hospitalist can report one unit of 99291 and one unit of 99292.

The Solution

Condition and Care

Code of the Month

Critical Care Services

99291: Critical care, evaluation, and management of the critically ill or critically injured patient; first 30-74 minutes.

99292: Critical care, evaluation, and management of the critically ill or critically injured patient; each additional list 30 minutes separately in addition to code for primary service.

Code 99292 is used to report additional blocks of time, of up to 30 minutes each beyond the first 74 minutes.

Duration

Critical care is a time-based service. It constitutes the physician’s time spent providing direct care at the bedside and gathering and reviewing data on the patient’s unit or floor.

Initial inpatient service (99221-99223);

Subsequent hospital care (99231-99233); or

Inpatient consultation (99251-99255).

Service Inclusions

Therefore, do not report the following services when billing 99291-99292:

Cardiac output measurements (93561, 93562);

Chest X-rays (71010, 71015, 71020);

Pulse oximetry (94760, 94761, 94762); and

Blood gases (multiple codes).

Further, don’t report interpretation of data stored in computers:

Electrocardiograms, blood pressures, hematologic data (99090);

Gastric intubation (43752, 91105);

Temporary transcutaneous pacing (92953);

Ventilation management (94002-94004, 94660, 94662); and

Vascular access procedures (36000, 36410, 36415, 36591, 36600).

Any other service or procedure provided by the physician can be billed in addition to 99291-99292.

Location

Bed location alone does not determine critical-care reporting. Patients assigned to an ICU might be critically ill or injured and meet the “condition” requirements for 99291-99292.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

Code These Cases

The Solution

Family meeting time can be counted toward critical-care service time when:

The patient is unable or clinically incompetent to participate in discussions;

Time is spent on the unit/floor with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care;

The conversation bears directly on the management of the patient. Meetings that take place for grief counseling involving the patient’s family (90846, 90847, 90849) are not reported separately or included as part of the critical-care time.

This scenario meets the criteria for inclusion in critical-care time. A total of 75 minutes was spent for the day. The hospitalist can report one unit of 99291 and one unit of 99292.

The Solution

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Plan for Discharge

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Discharge planning typically begins at the time of admission. Physicians and hospital staff manage the patient’s acute issues throughout the stay while simultaneously trying to anticipate the patient’s discharge needs. Physicians capture these associated efforts by reporting discharge day management codes 99238 or 99239.

Code Use

Use of discharge day management codes 99238-99239 is reserved for the admitting physician/group, unless a formal transfer of care occurs (e.g., patient is transferred from the intensive care unit by the critical care physician to the medical-surgical floor on the hospitalist’s service).

Code of the Month

Discharge Management

99238: Hospital discharge day management, 30 minutes or less.

99239: Hospital discharge day management, more than 30 minutes.

The hospital discharge day management codes are to be used to report the total time spent by a physician for final hospital discharge of a patient. The codes include, as appropriate:

Final examination of the patient;

Discussion of the hospital stay, even if the time spent by the physician on that date is not continuous;

Instructions for continuing care to all relevant caregivers; and

Preparation of discharge records, prescriptions, and referral forms.

Report one discharge code per hospitalization, but only when the service occurs after the initial date of admission. Codes 99238 or 99239 are not permitted for use when the patient is admitted and discharged on the same calendar date. When this occurs, the physician selects from 99221-99223 (initial inpatient care) or 99234-99236 (admission and discharge on the same day). Choose 99234-99238 when the patient stay is eight or more hours on the same calendar day and the insurer accepts these codes.

Documentation must also reflect two components of service: the corresponding elements of both the admission and discharge. Alternately, if the patient stays less than eight hours, or the insurer does not recognize 99234-99236 (admission and discharge on the same day), report 9922x (initial inpatient care) as appropriate.

Don’t mistakenly report discharge services for merely dictating the discharge summary. Discharge day management, as with most payable evaluation and management (E/M) services, requires a face-to-face visit between the physician and the patient on discharge day.

The entire visit need not take place at the bedside and may include other discharge-related elements performed on the patient’s unit/floor such as discussions with other healthcare professionals, patient/caregiver instruction and coordination of follow-up care. The discharge code description indicates that a final examination of the patient is included, but only “as appropriate.” In other words, an exam may not occur, or may not be documented, yet this does not preclude the physician from reporting 99238-99239. However, inclusion of the exam in the discharge day documentation is the best way to justify that a face-to-face service occurred on discharge day. This may be included in the discharge summary or a separate progress note in the medical record.

Code These Cases

Case 1: An otherwise healthy 58-year-old male patient is admitted by the surgical team for a hip fracture. The hospitalist is asked to see the patient postoperatively. The surgeon completes the necessary postoperative check and asks the hospitalist to discharge the patient. What service(s) can the hospitalist report?

The Solution

The hospitalist is not part of the same specialty provider group and so may report subsequent hospital care code 9923x. In order to submit a claim for this service, the hospitalist must not be acting under a formal transfer of care (i.e., the surgeon asks the hospitalist to assume postoperative care of the patient).

Otherwise, the service is considered part of the surgeon’s global package. Either the surgeon and the hospitalist must submit separate claims for their respective portions of care, or the hospitalist must obtain the appropriate portion of the surgical package payment from the surgeon.

Billing for subsequent hospital care (9923x) also requires medical necessity—a reason for the hospitalist’s involvement. The “otherwise healthy” patient may not have medical issues unrelated to the surgery.

If this is the case, the diagnosis code submitted with 9923x involves only the surgical issues already included in the surgical package payment. Therefore, the work involved in discharging the patient becomes an unpaid administrative effort.

Case 2: The hospitalist sees the patient the day before discharge, documenting the patient’s discharge orders and instructions pending negative lab results. The patient leaves the hospital the following day. The hospitalist never sees the patient on that last day but completes all the necessary paperwork. Can the hospitalist report appropriate discharge day management code 99238-99239 on the date before the actual discharge?

The Solution

No. Discharge day management may be reported only on the final day of the hospitalization, and only when the physician sees the patient (i.e., a face-to-face service). Report the service provided the day prior to discharge with the appropriate subsequent hospital care code (99231-99233). No service should be reported on the final day of hospitalization for the above scenario.

Time-Based Service

Discharge day management codes reflect the time accumulated on a calendar date, ending when the patient physically leaves the hospital. Services performed in a location other than the patient’s unit/floor (e.g., dictating the discharge summary from the outpatient office), do not count toward the cumulative time. Additionally, discharge-related services performed by residents, students or ancillary staff (i.e., registered nurses), such as reviewing instructions with the patient, do not count toward the discharge service time.

To support the discharge day management claim, documentation should reference the discharge status and other clinically relevant information. Time is not required when documenting 99238 because this service code constitutes any amount of time up to and including 30 minutes. When reporting 99239, documentation must include the physician’s cumulative service time (more than 30 minutes).

Medicare currently initiates a prepayment review (i.e., request for documentation to review the service prior to any payment consideration) for claims involving 99239. Failure to respond to the prepayment request or failure to include the time component in the documentation often results in claim denial. Payment can be recovered only through the appeal process or claim correction, when applicable.

Rules For Surgery

Surgeons are prohibited from separately reporting inpatient postoperative services related to the surgery, including discharge day management (99238-99239). Additionally, when the surgeon admits a patient to the hospital and discharge services are performed postoperatively by the hospitalist, discharge day management is included in the surgical package.

The reasons are two-fold: If the surgeon transfers the remaining inpatient care to the hospitalist, these discharge services are considered part of the global surgical package.

If no transfer occurs (as the surgeon is typically responsible and paid for all care up to 90 days following surgery), only the admitting physician/group (i.e., the surgeon) may report discharge day management codes 99238-99239.

In the latter scenario, the hospitalist reports subsequent hospital care (99231-99233) for all medically necessary services involving the patient’s medical management, even if provided on the day of discharge.

Pronouncement of Death

One of the most underreported services involves pronouncement of death. A physician who performs this service may qualify to report discharge day management code 99238-99239. To pronounce death, the physician must examine the patient, thus satisfying the face-to-face visit requirement.

Additionally, the physician may have to coordinate the necessary services, speak with family members or other healthcare providers, and fill out the necessary documentation.

If performed on the patient’s unit/floor, these services count toward the cumulative discharge service time. Documentation must include the time (if reporting 99239) as well as the patient’s discharge status and clinically relevant information. Completion of the death certificate alone is not sufficient for billing. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

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Code Use

Code of the Month

Discharge Management

99238: Hospital discharge day management, 30 minutes or less.

99239: Hospital discharge day management, more than 30 minutes.

The hospital discharge day management codes are to be used to report the total time spent by a physician for final hospital discharge of a patient. The codes include, as appropriate:

Final examination of the patient;

Discussion of the hospital stay, even if the time spent by the physician on that date is not continuous;

Instructions for continuing care to all relevant caregivers; and

Preparation of discharge records, prescriptions, and referral forms.

Code These Cases

The Solution

Time-Based Service

Rules For Surgery

The reasons are two-fold: If the surgeon transfers the remaining inpatient care to the hospitalist, these discharge services are considered part of the global surgical package.

Pronouncement of Death

Additionally, the physician may have to coordinate the necessary services, speak with family members or other healthcare providers, and fill out the necessary documentation.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

Code Use

Code of the Month

Discharge Management

99238: Hospital discharge day management, 30 minutes or less.

99239: Hospital discharge day management, more than 30 minutes.

The hospital discharge day management codes are to be used to report the total time spent by a physician for final hospital discharge of a patient. The codes include, as appropriate:

Final examination of the patient;

Discussion of the hospital stay, even if the time spent by the physician on that date is not continuous;

Instructions for continuing care to all relevant caregivers; and

Preparation of discharge records, prescriptions, and referral forms.

Code These Cases

The Solution

Time-Based Service

Rules For Surgery

The reasons are two-fold: If the surgeon transfers the remaining inpatient care to the hospitalist, these discharge services are considered part of the global surgical package.

Pronouncement of Death

Additionally, the physician may have to coordinate the necessary services, speak with family members or other healthcare providers, and fill out the necessary documentation.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

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Daily Care Conundrums

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Subsequent hospital care, also known as daily care, presents a variety of daily-care scenarios that cause confusion for billing providers.

Subsequent hospital care codes are reported once per day after the initial patient encounter (e.g., admission or consultation service), but only when a face-to-face visit occurs between provider and patient.

The entire visit need not take place at the bedside. It may include other important elements performed on the patient’s unit/floor such as data review, discussions with other healthcare professionals, coordination of care, and family meetings. In addition, subsequent hospital care codes represent the cumulative evaluation and management service performed on a calendar date, even if the hospitalist evaluates the patient for different reasons or at different times throughout the day.

Code of the Month

SUBSEQUENT CARE

99231: Subsequent hospital care, per day, for the evaluation and management of a patient that requires at least two of three key components:

A problem focused interval history;

A problem focused examination; or

Medical decision-making that is straightforward or of low complexity.

Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Hospitalists typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

99232: Subsequent hospital care, per day, for the evaluation and management of a patient that requires at least two of three key components:

An expanded problem-focused interval history;

An expanded problem-focused examination; or

Medical decision-making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Hospitalists typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.

99233: Subsequent hospital care, per day, for the evaluation and management of a patient that requires at least two of three key components:

A detailed interval history;

A detailed examination; or

Medical decision-making of high complexity.

Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Hospitalists typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

These codes are used for new or established patients. An established patients has received face-to-face services from a hospitalist or someone from the hospitalist’s group within the past three years. The hospitalist does not have to spend the associated “typical” visit time with the patient to report an initial hospital care code. Time is only considered when more than 50% of the total visit time is spent counseling/coordinating patient care. See Section 30.6.1C, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf for more information about reporting visit level based on time.

Concurrent Care

Traditionally, concurrent care occurs when physicians of different specialties and group practices participate in a patient’s care. Each physician manages a particular aspect while considering the patient’s overall condition.

When submitting claims for concurrent care services, each physician should report the appropriate subsequent hospital care code and the corresponding diagnosis each primarily manages. If billed correctly, each hospitalist will have a different primary diagnosis code and be more likely to receive payment.

Some managed-care payers require each hospitalist to append modifier 25 to their evaluation and management (E/M) visit code (99232-25) even though each submits claims under different tax identification numbers. Modifier 25 is a separately identifiable E/M service performed on the same day as a procedure or other E/M service. In this situation, Medicare is likely to reimburse as appropriate.

Payment by managed-care companies is less easily obtained: Payment for the first received claim is likely, and denial of any claim received beyond the first claim is inevitable. Appealing the denied claims with documentation for each hospitalist’s visit on a given date helps the payer understand the need for each service.

Group Practice

When concurrent care is provided by members of the same group practice, claim reporting becomes more complex. Physicians in the same group practice and specialty bill and are paid as though to a single physician. In other words, if two hospitalists evaluate a patient on the same day (e.g., one hospitalist sees the patient in the morning, and another one sees the patient in the afternoon), the efforts of each medically necessary evaluation and management service may be captured.

However, the billing mechanism used in this situation varies from the standard. Instead of reporting each service separately under each corresponding hospitalist’s name, the hospitalists select subsequent hospital care code 99231-99233 representing the combined visits and submit one appropriate code for the collective level of service.

The difficulty is selecting the name that will appear on the claim form. Solutions range from reporting the hospitalist who provided the first encounter of the day to identifying the hospitalist who provided the most extensive or best-documented encounter of the day. For productivity analysis, some practices develop an internal accounting system and credit each hospitalist for their medically necessary joint efforts. The latter option is a labor-intensive task for administrators.

Physicians in the same group practice but different specialties may bill and be paid without regard to their membership in the same group. For example, a hospitalist and an infectious disease specialist may be part of the same multispecialty group practice and bill under a group tax-identification number, yet qualify for separate payment.

This is permitted if each physician has a differing specialty code designation. Specialty codes are self-designated, two-digit representations that describe the kind of medicine physicians, non-physician practitioners, or other healthcare providers/suppliers practice. They are initially selected and registered with each payer during the enrollment process.

A list of qualifying specialty codes can be found at www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/SpecialtyCodes2207.pdf.

Covering Physicians

Hospital inpatient situations involving physician coverage are complicated. If Dr. Richards sees the patient earlier in the day and Dr. Andrews, covering for Dr. Richards, sees the same patient later that same day, Dr. Andrews cannot be paid for the second visit.

Subsequent hospital care descriptors emphasize “per day” to account for all care provided during the calendar day. Insurers treat the covering physician as if he were the physician being covered. Services provided by each are handled in the same manner described above.

If each hospitalist is responsible for a different aspect of the patient’s care, payment is made for both visits if:

The hospitalists are in different specialties and different group practices;

The visits are billed with different diagnoses; and

The patient is a Medicare beneficiary or a member of an insurance plan that adopts Medicare rules.

There are limited circumstances where concurrent care can be billed to Medicare by hospitalists of the same specialty (e.g., an internist and a hospitalist, one with significant and demonstrated expertise in pain management).

Each hospitalist must belong to a different group practice and submit claims under different tax identification numbers. The patient’s condition must require the expertise possessed by the “sub-specialist.” Payment will be denied in the initial claim determination. But formulating a Medicare appeal with documentation from both encounters can demonstrate the medical necessity and separateness of each service and help earn reimbursement—although it is not guaranteed.

Managed-care payment for two visits on the same day by physicians of the same registered specialty (e.g., internal medicine), regardless of sub-specialization, is highly unlikely. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

Code These Cases

Case 1: A 65-year-old patient is admitted for chest pain and to rule out myocardial infarction. The patient also has chronic obstructive pulmonary disease (COPD) and type 2 diabetes. The cardiologist manages the patient’s cardiovascular compromise, while the hospitalist provides daily care for COPD and diabetes. What service(s) can the hospitalist report?

The Solution

The medical necessity of each service and the expertise of each hospitalist is evident. The hospitalist reports appropriate subsequent hospital care code 9923x with 250.00 (diabetes mellitus without mention of complication, type 2 or unspecified type, not stated as uncontrolled and 496 COPD, not otherwise specified). Modifier 25 may be required by some payers when the hospitalist and the cardiologist submit a subsequent hospital care claim on the same day, and payment is never guaranteed. If denied, appeal with both sets of documentation.

Case 2: A hospitalist admits an uncontrolled diabetic patient after midnight. Later that day, the patient’s internist assumes care of the patient. If the hospitalist provides night coverage for the internist on the second day and each hospitalist saw the patient on the second day and addressed the diabetic condition, what should each hospitalist report on Day 2?

The Solution

The internist who assumed complete care of the patient can report appropriate subsequent hospital care code 9923x associated with 250.02 (diabetes mellitus without mention of complication, type 2 or unspecified type, uncontrolled). The hospitalist’s service may be difficult to justify for additional payment because he provided coverage for the internist, they are physicians of the same specialty, and each treated the same condition. If the hospitalist reports his service and the payer receives this claim before the internist’s, the hospitalist may be paid and internist denied. To recover costs and avoid internal conflict, some hospitalist groups contract with the hospital and receive a stipend for night coverage. It is best to seek legal advice before pursuing this option to prevent inappropriate arrangements.

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Subsequent hospital care, also known as daily care, presents a variety of daily-care scenarios that cause confusion for billing providers.

Code of the Month

SUBSEQUENT CARE

99231: Subsequent hospital care, per day, for the evaluation and management of a patient that requires at least two of three key components:

A problem focused interval history;

A problem focused examination; or

Medical decision-making that is straightforward or of low complexity.

99232: Subsequent hospital care, per day, for the evaluation and management of a patient that requires at least two of three key components:

An expanded problem-focused interval history;

An expanded problem-focused examination; or

Medical decision-making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Hospitalists typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.

99233: Subsequent hospital care, per day, for the evaluation and management of a patient that requires at least two of three key components:

A detailed interval history;

A detailed examination; or

Medical decision-making of high complexity.

Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Hospitalists typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

Concurrent Care

Group Practice

A list of qualifying specialty codes can be found at www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/SpecialtyCodes2207.pdf.

Covering Physicians

If each hospitalist is responsible for a different aspect of the patient’s care, payment is made for both visits if:

The hospitalists are in different specialties and different group practices;

The visits are billed with different diagnoses; and

The patient is a Medicare beneficiary or a member of an insurance plan that adopts Medicare rules.

Managed-care payment for two visits on the same day by physicians of the same registered specialty (e.g., internal medicine), regardless of sub-specialization, is highly unlikely. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

Code These Cases

The Solution

Subsequent hospital care, also known as daily care, presents a variety of daily-care scenarios that cause confusion for billing providers.

Code of the Month

SUBSEQUENT CARE

99231: Subsequent hospital care, per day, for the evaluation and management of a patient that requires at least two of three key components:

A problem focused interval history;

A problem focused examination; or

Medical decision-making that is straightforward or of low complexity.

99232: Subsequent hospital care, per day, for the evaluation and management of a patient that requires at least two of three key components:

An expanded problem-focused interval history;

An expanded problem-focused examination; or

Medical decision-making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Hospitalists typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.

99233: Subsequent hospital care, per day, for the evaluation and management of a patient that requires at least two of three key components:

A detailed interval history;

A detailed examination; or

Medical decision-making of high complexity.

Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Hospitalists typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

Concurrent Care

Group Practice

A list of qualifying specialty codes can be found at www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/SpecialtyCodes2207.pdf.

Covering Physicians

If each hospitalist is responsible for a different aspect of the patient’s care, payment is made for both visits if:

The hospitalists are in different specialties and different group practices;

The visits are billed with different diagnoses; and

The patient is a Medicare beneficiary or a member of an insurance plan that adopts Medicare rules.

Managed-care payment for two visits on the same day by physicians of the same registered specialty (e.g., internal medicine), regardless of sub-specialization, is highly unlikely. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

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When consultation services occur in inpatient and outpatient settings, physicians report the code category that best corresponds to the patient’s registered status at the time of service:

Inpatient consultation (99251-99255) for services provided to an inpatient (acute care, inpatient rehabilitation, inpatient psychiatric, long-term acute care, or skilled nursing); or

Outpatient consultation (99241-99245) for services provided to an outpatient (office, emergency department [ED], or observation care).

Regardless of location, consultants must meet each requirement before submitting a claim for these services. This article focuses on the coding and billing nuances of inpatient consultation services; outpatient consultations provided in the ED or during observation care will be addressed in a future issue.

Code of the Month

ADMISSION CONSULTS

99251: Inpatient consultation, which requires these three key components:

A problem-focused history;

A problem-focused examination; and

Straightforward medical decision-making.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limiting or minor. Physicians typically spend 20 minutes at the bedside and on the patient’s hospital floor or unit.

99252: Inpatient consultation, which requires these three key components:

An expanded problem-focused history;

An expanded problem-focused examination; and

Straightforward medical decision-making.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient’s hospital floor or unit.

99253: Inpatient consultation, which requires these three key components:

A detailed history;

A detailed examination; and

Medical decision-making of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient’s hospital floor or unit.

99254: Inpatient consultation, requires three key components:

A comprehensive history;

A comprehensive examination; and

Medical decision-making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient’s hospital floor or unit.

99255: Inpatient consultation, which requires these three key components:

A comprehensive history;

A comprehensive examination; and

Medical decision-making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 110 minutes at the bedside and on the patient’s hospital floor or unit.

These codes are used for new or established patients (those who have received face-to-face services from a physician or someone from the physician’s group within the past three years). The physician does not have to spend the associated “typical” visit time with the patient in order to report an initial hospital care code. Time is only considered when more than 50% of the total visit time is spent counseling/coordinating patient care. See Section 30.6.1C, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf for more information about reporting visit level based on time.

The Three R’s

Reason and request: Consultants (physicians or qualified non-physician providers) are asked to give an opinion or recommendation, a suggestion, direction, or counsel in the treatment of a patient’s condition because the consultant has expertise in a specific medical area beyond the requesting professional’s knowledge.

The requesting professional must be a physician or other qualified healthcare provider (e.g., nurse practitioner, physician assistant, resident acting under guidance of a teaching physician) currently involved in the patient’s care. Do not report consultation codes when a patient, family member, or third party requests a second opinion. Instead, select the most appropriate subsequent hospital care code (99231-99233).

The request must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting provider and the consulting physician; however, when this occurs, the verbal conversation must be documented by both the consultant (in the progress note) and the requesting provider (in the plan of care or as a written order). Standing orders for consultation are prohibited. Clearly document the reason for the service: the patient’s condition, sign, or symptoms that prompted the consult request, ensuring the medical necessity of the service.

Try to avoid terminology, such as “Consult hospitalist for perioperative management.” This leads to the payer’s confusion about co-management issues. The documentation should reflect the true intent of the service: “Consult hospitalist for perioperative risk assessment.” If necessary, ask the requesting provider to clarify the request. The consultant should further explain the request in his/her own note.

Report: After the patient’s assessment, the consultant documents the service and prepares a written report for the requesting provider, which includes the written request, consultation evaluation, findings, and recommendations.

It is appropriate for the consultant to initiate diagnostic services and treatment at the initial consultation service or at a subsequent visit, yet still qualify as a consult. In the inpatient setting, it is acceptable for the consultant’s report to appear as an entry in the shared medical record without need to forward a separate document to the requesting provider.

Code Use

Inpatient consultation codes are reported once per hospitalization. If reported more frequently, all claims within the same hospitalization subsequently reported with codes 99251-99255 are denied. This happens even when the consultant signs off and is re-consulted for a different problem during the same hospitalization.

A physician who provides patient services after the initial consultation reports subsequent hospital care codes 99231-99233 for each date in which a face-to-face encounter occurs.

A physician or qualified nonphysician provider may request a consultation from a member of the same group practice as long as the consultant possesses a legitimate expertise in a specific medical area beyond the requesting professional’s knowledge (e.g., a hospitalist may consult a member of his group who specializes in infectious disease).

This situation is likely to produce a rejected consult claim. In appealing the claim, submit notes from each member of the group (i.e., the requesting provider and the consultant) to demonstrate medical necessity and distinguish the expertise involved in each service. Medicare and payers who follow Medicare guidelines should reimburse the consult after the documentation is reviewed.

Co-management

Preoperative consults: Preoperative consultations are permitted when performed by any physician or qualified nonphysician provider at the request of a surgeon—as long as all requirements for performing and reporting the consultation codes are met. The service must be medically necessary and not provided for routine screening (i.e., consults for healthy patients scheduled for elective surgery).

Postoperative management: If a physician or qualified nonphysician provider who has performed a preoperative consultation is subsequently consulted and/or assumes responsibility for the complete or partial management of the patient’s condition(s) during the postoperative period, the appropriate subsequent hospital care code 99231-99233 is used.

Additionally, do not report consultation codes when the surgeon asks the hospitalist to take responsibility for the management of an aspect of the patient’s condition during the postoperative period (i.e., consult for postoperative management). In this situation, the surgeon is not asking the consultant for an opinion or advice for the surgeon’s use in treating the patient, and the surgeon is not expected to continue on the case. This constitutes concurrent care and is billed with the appropriate subsequent hospital care codes.

Alternately, the surgeon may continue on the case, not transferring the care for the remaining portion of the hospitalization to the hospitalist, and incorporating the hospitalist’s recommendations into his/her own care plan, subsequently retaining the hospitalist’s services in assisting with care. Because the transfer did not occur prior to the consultation, this situation may constitute an inpatient consultation and be reported as such.

Unfortunately, some local Medicare contractors do not recognize this latter distinction and prohibit reporting post-surgical involvement with 99251-99255. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

Code These Cases

Case 1: A surgeon admits a patient for a fractured hip. This 75-year-old white female has a longstanding history of hypertension and chronic obstructive pulmonary disease (COPD). Upon admission, the patient’s blood pressure is significantly elevated with (self-reported) elevated readings over the past week. The surgeon requests a consult for assessment and treatment of uncontrolled hypertension. What service(s) can the hospitalist report?

The Solution

The surgeon requested the hospitalist’s opinion regarding uncontrolled hypertension. The request is documented in the medical record, the hospitalist performs the evaluation and documents his recommendations. Given the nature of the patient’s condition, the hospitalist initiates treatment and remains on the case. The hospitalist reports the appropriate level of consultation (99251-99255) with the codes ICD-9-CM 401.9 (essential hypertension, unspecified) and 496 (COPD, not otherwise specified).

Case 2: The patient in the first case is medically stabilized and the surgeon proceeds with surgery. Postoperatively, the patient’s COPD begins to flare as her respiratory status is compromised by the anesthesia. The surgeon requests the hospitalist’s advice on the postoperative management of the patient’s COPD. What service(s) can the hospitalist report?

The Solution

Because the hospitalist provided preoperative care to the patient, only subsequent hospital care codes 99231-99233 with 496 (COPD, not otherwise specified) and 401.9 (essential hypertension, unspecified) for the postoperative involvement may be reported, even though the consult is requested for different problem.

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When consultation services occur in inpatient and outpatient settings, physicians report the code category that best corresponds to the patient’s registered status at the time of service:

Inpatient consultation (99251-99255) for services provided to an inpatient (acute care, inpatient rehabilitation, inpatient psychiatric, long-term acute care, or skilled nursing); or

Outpatient consultation (99241-99245) for services provided to an outpatient (office, emergency department [ED], or observation care).

Code of the Month

ADMISSION CONSULTS

99251: Inpatient consultation, which requires these three key components:

A problem-focused history;

A problem-focused examination; and

Straightforward medical decision-making.

99252: Inpatient consultation, which requires these three key components:

An expanded problem-focused history;

An expanded problem-focused examination; and

Straightforward medical decision-making.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient’s hospital floor or unit.

99253: Inpatient consultation, which requires these three key components:

A detailed history;

A detailed examination; and

Medical decision-making of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient’s hospital floor or unit.

99254: Inpatient consultation, requires three key components:

A comprehensive history;

A comprehensive examination; and

Medical decision-making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient’s hospital floor or unit.

99255: Inpatient consultation, which requires these three key components:

A comprehensive history;

A comprehensive examination; and

Medical decision-making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 110 minutes at the bedside and on the patient’s hospital floor or unit.

The Three R’s

Code Use

A physician who provides patient services after the initial consultation reports subsequent hospital care codes 99231-99233 for each date in which a face-to-face encounter occurs.

Co-management

Unfortunately, some local Medicare contractors do not recognize this latter distinction and prohibit reporting post-surgical involvement with 99251-99255. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

Code These Cases

The Solution

When consultation services occur in inpatient and outpatient settings, physicians report the code category that best corresponds to the patient’s registered status at the time of service:

Inpatient consultation (99251-99255) for services provided to an inpatient (acute care, inpatient rehabilitation, inpatient psychiatric, long-term acute care, or skilled nursing); or

Outpatient consultation (99241-99245) for services provided to an outpatient (office, emergency department [ED], or observation care).

Code of the Month

ADMISSION CONSULTS

99251: Inpatient consultation, which requires these three key components:

A problem-focused history;

A problem-focused examination; and

Straightforward medical decision-making.

99252: Inpatient consultation, which requires these three key components:

An expanded problem-focused history;

An expanded problem-focused examination; and

Straightforward medical decision-making.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient’s hospital floor or unit.

99253: Inpatient consultation, which requires these three key components:

A detailed history;

A detailed examination; and

Medical decision-making of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient’s hospital floor or unit.

99254: Inpatient consultation, requires three key components:

A comprehensive history;

A comprehensive examination; and

Medical decision-making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient’s hospital floor or unit.

99255: Inpatient consultation, which requires these three key components:

A comprehensive history;

A comprehensive examination; and

Medical decision-making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 110 minutes at the bedside and on the patient’s hospital floor or unit.

The Three R’s

Code Use

A physician who provides patient services after the initial consultation reports subsequent hospital care codes 99231-99233 for each date in which a face-to-face encounter occurs.

Co-management

Unfortunately, some local Medicare contractors do not recognize this latter distinction and prohibit reporting post-surgical involvement with 99251-99255. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

Code These Cases

The Solution

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Demystify Admissions

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Physicians may encounter patients in various ways during the first few days of a hospitalization: admission services, consultations, and medical-surgical co-management.

Submitting claims for these services is often inconsistent and inaccurate because billing education is not a standard part of medical education.

In an attempt to clarify the rules and reduce frustration, I will address billing, coding, and reimbursement guidelines for each type of initial hospital encounter over the next several issues.

Code of the Month Initial Hospital Care

99221: Initial hospital care, per day, for evaluation and management of a patient that requires:

A detailed or comprehensive history;

A detailed or comprehensive examination; and

Straightforward or low complexity medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.

99222: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:

A comprehensive history;

A comprehensive examination; and

Moderately complex medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit.

99223: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:

A comprehensive history;

A comprehensive exam; and

Highly complex medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.

Note: These codes are used for new or patients. The physician does not have to spend the associated “typical” visit time with the patient to report an initial hospital care code. Time is only considered when more than half the visit is spent counseling/coordinating patient care. See Section 30.6.1C (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf) for more information about reporting visit level based on time.

Definition

Initial Hospital Care (IHC) comprises all services related to the patient’s admission to an acute care facility. An acute care facility is any that registers inpatients but does not have a corresponding Current Procedural Terminology (CPT) code category for claim reporting. Acute care facilities also include “partial hospitals.”

For example, admissions to inpatient rehabilitation are reported with IHC codes 99221-99223, while nursing facility admissions have a designated category and are best reported with CPT codes 99304-99306 for Initial Nursing Facility Care.

Code Use

IHC codes are reported once per hospitalization and reserved for the physician/group assuming primary responsibility for the patient’s care during that time.

If reported more frequently, all claims within the same hospitalization subsequently reported with codes 99221-99223 are denied or rejected pending review of documentation to ascertain the correct service date and responsible party. This is common because physicians confuse code description IHC with its true intent. They mistakenly report these codes for their first inpatient encounter, regardless of the encounter date or the admitting physician/group.

Specialists assisting in the patient’s management and not primarily responsible for the entire hospitalization report the code category that best reflects the performed service and documentation—as long as the selected category requirements are met. The physician selects from either Inpatient Consultation codes 99251-99255 or Subsequent Hospital Care (SHC) codes 99231-99233. Any physician who provides patient services after the initial encounter, including those by the responsible attending physician/group or a specialist concurrently involved in the patient’s care, reports SHC codes for each date in which a face-to-face encounter occurs.

When services begin in one location (e.g., physician’s office, emergency department, or observation) and end with an inpatient admission on the same calendar day, the physician reports only the most appropriate initial hospital care code. It is not necessary for the physician to duplicate the information from the earlier encounter for the admission service. Instead, the physician can forward a copy of the progress note from the earlier encounter to the inpatient chart, along with the documented decision for admission and pertinent information obtained throughout the day. Auditors consider the culmination of all chart entries in a given date when reviewed. When services begin in one location but end with an admission on different calendar day, the physician separately reports each service provided on each date: 99220 on Day 1 and 99223 on Day 2.

Intrafacility Transfers

Patients may receive different components of inpatient services within the same (uninterrupted) episode of care, all within the same building but treated as separate facility admissions (e.g., rehabilitation or long-term acute care).

It is unlikely the attending physician of record during the acute care phase will also be the attending physician during the second phase of care. Should this occur, Medicare contractors and those payers who follow Medicare guidelines permit the attending physician to separately report the acute care discharge (99238-99239) and the secondary admission (99221-99223), but only in the absence of a shared medical record (see Section 30.6.9.1D,www.cms.hhs.gov/manuals/downloads/clm104c12.pdf). If a common chart is used, the physician reports the secondary admission services as ongoing care, using SHC codes 99231-99233 instead.

Similarly, transfers occur within a single phase of care, such as transfers to and from a medical intensive care unit and a standard medical-surgical unit. Such transfers are not treated as separate admissions, and the receiving physician reports only the SHC codes because the IHC service was previously reported by the admitting physician/group. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia.

Code This Case

A hospitalist admits a patient to observation for chest pain to rule out myocardial infarction at 11 p.m. on Day 1.

Early on Day 2, test results, including serial electrocardiograms, cardiac enzyme and troponin levels, and echocardiography, confirm suspicions, and the physician admits the patient for treatment.

The inpatient admission documentation includes a detailed history and exam (because a complete history and exam, along with high complexity decision making, was previously recorded upon admission to observation) and high complexity medical decision-making. What service(s) can the hospitalist report?

The Solution

The hospitalist can potentially report two services because each occurred on a different calendar day; this assumes that the documentation and billing requirements for each service are met. The hospitalist must document the inpatient admission service separately from the observation admission, and only portions of the documentation from the observation admission can be counted toward the inpatient admission information.

The Centers for Medicare and Medicaid Services Documentation Guidelines for Evaluation and Management Services (E/M) is considered the gold standard of E/M resources. It indicates the physician must redocument the history of present illness (HPI), physical exam and medical decision-making (MDM) when referencing encounters from a previous date of service. In other words, the hospitalist can reference, by date, the review of systems and past, family, and social histories without having to redocument these elements. However, the hospitalist must reconfirm the HPI, reperform the physical exam, reconsider the plan of care, and redocument each of these items in a currently dated progress note.

Assuming separate notes were appropriately documented with the levels of history, exam and MDM indicated in the scenario above, the hospitalist reports 99220 for chest pain (ICD-9-CM 786.50) on Day 1 and 99221 for anterolateral myocardial infarction (ICD-9-CM 410.01) on Day 2.

Although the documentation for the inpatient admission service included high-complexity MDM, the hospitalist selects the visit level supported by each of the key components (i.e., history exam, and decision making). The lowest component determines the visit level; a detailed history and exam with high complexity MDM only supports 99221.

In contrast, if the hospitalist documented a single, yet cumulative, note with a comprehensive history and physical exam, and high complexity MDM on Day 2, he/she may report only the inpatient admission service (99223) unless the note identified each date and their corresponding components of documentation.

More information regarding the key components and guidelines for E/M documentation is available at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp.—CP

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Physicians may encounter patients in various ways during the first few days of a hospitalization: admission services, consultations, and medical-surgical co-management.

Submitting claims for these services is often inconsistent and inaccurate because billing education is not a standard part of medical education.

In an attempt to clarify the rules and reduce frustration, I will address billing, coding, and reimbursement guidelines for each type of initial hospital encounter over the next several issues.

Code of the Month Initial Hospital Care

99221: Initial hospital care, per day, for evaluation and management of a patient that requires:

A detailed or comprehensive history;

A detailed or comprehensive examination; and

Straightforward or low complexity medical decision making.

99222: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:

A comprehensive history;

A comprehensive examination; and

Moderately complex medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit.

99223: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:

A comprehensive history;

A comprehensive exam; and

Highly complex medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.

Definition

Code Use

IHC codes are reported once per hospitalization and reserved for the physician/group assuming primary responsibility for the patient’s care during that time.

Intrafacility Transfers

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia.

Code This Case

A hospitalist admits a patient to observation for chest pain to rule out myocardial infarction at 11 p.m. on Day 1.

Early on Day 2, test results, including serial electrocardiograms, cardiac enzyme and troponin levels, and echocardiography, confirm suspicions, and the physician admits the patient for treatment.

The Solution

More information regarding the key components and guidelines for E/M documentation is available at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp.—CP

Physicians may encounter patients in various ways during the first few days of a hospitalization: admission services, consultations, and medical-surgical co-management.

Submitting claims for these services is often inconsistent and inaccurate because billing education is not a standard part of medical education.

In an attempt to clarify the rules and reduce frustration, I will address billing, coding, and reimbursement guidelines for each type of initial hospital encounter over the next several issues.

Code of the Month Initial Hospital Care

99221: Initial hospital care, per day, for evaluation and management of a patient that requires:

A detailed or comprehensive history;

A detailed or comprehensive examination; and

Straightforward or low complexity medical decision making.

99222: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:

A comprehensive history;

A comprehensive examination; and

Moderately complex medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit.

99223: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:

A comprehensive history;

A comprehensive exam; and

Highly complex medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.

Definition

Code Use

IHC codes are reported once per hospitalization and reserved for the physician/group assuming primary responsibility for the patient’s care during that time.

Intrafacility Transfers

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia.

Code This Case

A hospitalist admits a patient to observation for chest pain to rule out myocardial infarction at 11 p.m. on Day 1.

Early on Day 2, test results, including serial electrocardiograms, cardiac enzyme and troponin levels, and echocardiography, confirm suspicions, and the physician admits the patient for treatment.

The Solution

More information regarding the key components and guidelines for E/M documentation is available at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp.—CP

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