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Know What to Document

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Fri, 09/14/2018 - 12:35

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Know What to Document

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Carol Pohlig

Hospitalists who work in teaching hospitals need to understand the teaching physician (TP) rules, to know what qualifies for payment and how to document to receive that payment. TP services are payable when they are furnished by a physician who is not a resident or a resident with a teaching physician physically present during the critical or key portions of the service.

This article will focus on the documentation guidelines for inpatient services provided by the hospitalist in a teaching setting.

Evaluation and Management Services

Teaching physicians participate in evaluation and management (E/M) services with residents in several different ways. Below, three scenarios discuss documentation requirements:

Code This Case

The hospitalist rounds on a patient with the medical student. The student obtains a history, performs an exam and outlines the assessment and plan associated with the visit. The teaching physician supervises the entire service by the medical student. How should this service be reported?

the solution

Per Medicare guidelines, students (e.g., medical, nurse practitioner, etc.) may document services in the medical record. However, the teaching physician only may refer to medical student documentation associated with the review of systems and/or past/family/social history. The teaching physician may not refer to a student’s personal note for documentation of physical exam findings or medical decision making.

If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness, as well as perform and redocument the physical exam and medical decision making activities of the service. The teaching physician then selects the visit level most reflective of the performed and documented service.

Scenario One: The Stand-Alone Service. In this scenario, the teaching physician independently performs the entire service (i.e., all required elements of the billed visit) though the resident also may have seen the patient that same day. The TP may choose to document as if the care took place in a non-teaching setting. This documentation stands alone and independently supports the reported visit level.

Alternatively, the teaching physician may use the resident’s note. He or she does this by first documenting involvement in patient management and performance of the critical or key portion(s) of the service, and then linking to the resident’s note. The teaching physician selects the visit level based on the combined documentation (i.e., that of the teaching physician and the resident).

When referencing resident documentation, the teaching physician should use Medicare-approved linkage statements. Common examples include the following:

“I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

“I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”

“I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder than documented, so I will obtain an echo to evaluate.”

Although all of these examples are acceptable, the last one best identifies the teaching physician’s involvement in patient management, which is a requirement of TP documentation.

Scenario Two: The Supervised Service. In this scenario, resident and teaching physician provide services simultaneously. The teaching physician either may supervise the resident’s performance of required service elements or personally perform some of them.

Medicare Definitions for Teaching Services

Critical or Key Portion: The part, or parts, of a service the teaching physician determines are critical or key. For purposes of this section, these terms are interchangeable.

Direct Medical and Surgical Services: To individual beneficiaries that are either furnished by a physician or by a resident under the supervision of a physician in a teaching hospital.

Physically Present: The teaching physician and the patient are in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) and/or the physician performs a face-to-face service.

Resident: An individual who participates in an approved graduate medical education (GME) program or a physician not in an approved GME program but who is authorized to practice only in a hospital setting. The term includes interns and fellows in GME programs approved for purposes of direct GME payments made by the fiscal intermediary (FI). Receiving a staff or faculty appointment or participating in a fellowship does not, by itself, alter the status of resident. This status remains unaffected regardless of whether a hospital includes the physician in its full-time-equivalency count of residents.

Student: An individual who participates in an accredited educational program at a medical school that is not an approved GME program. A student is never considered an intern or a resident. Medicare does not pay for any service furnished by a student.

Teaching Hospital: A hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry or podiatry.

Teaching Physician: A physician (other than a resident) who involves residents in the care of his or her patients.

Teaching Setting: Any setting in which the FI makes Medicare payments for the services of residents under the direct graduate medical education payment methodology.

Documentation includes information about the teaching physician’s presence during the encounter, performance of the critical or key portions of the service and involvement in patient management, as well as a reference to the resident’s note. As in scenario one, the teaching physician selects the visit level based on the combined documentation.

Teaching physician statements associated with scenario two and accepted by Medicare reviewers include the following:

“I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”

“I saw the patient with the resident and agree with the resident’s findings and plan.”

Scenario two examples contain generalized statements considered acceptable for billing under teaching physician rules. Documenting patient-specific elements of the assessment and plan, however, not only demonstrate teaching physician involvement in patient care, but also evidence better quality of care.

Scenario Three: The Shared Service. In this case, the resident performs a portion or all of the required service elements without the teaching physician present and then documents the services. The teaching physician independently performs only the critical, or key, portions of the service and, as appropriate, discusses the case with the resident. Similar to scenario two, the TP references the resident’s note and documents presence during the encounter, performance of the critical or key portions of the service and involvement in patient management.

Remember, the teaching physician can not link to a resident note that does not exist. In other words, if the resident’s note is not available when the teaching physician is documenting, the note cannot be considered for billing purposes. When documented appropriately, as in the scenarios above, the teaching physician selects the visit level based on the combined documentation.

Medicare-approved linkage statements for use by teaching physicians in this scenario include the following:

“I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”

“I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”

“See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”

“I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Documentation of teaching physician presence and participation provided solely by the resident is not sufficient to support the teaching physician service. Some examples of unacceptable documentation include:

“Agree with above,” followed by legible countersignature or identity;

“Rounded, Reviewed, Agree,” followed by legible countersignature or identity;

“Discussed with resident. Agree,” followed by legible countersignature or identity;

“Seen and agree,” followed by legible countersignature or identity;

“Patient seen and evaluated,” followed by legible countersignature or identity; and

Legible countersignature or identity alone.

Time-Based Services

Time-based E/M services require the teaching physician be present for the entire period for which the claim is made. Medical record documentation should reflect the teaching physician’s total visit time (i.e., spent on the unit/floor for inpatient services), including face-to-face time with the patient.

Time spent by the resident without the presence of the teaching physician does not count toward the teaching physician’s time, nor does time the TP spends teaching activities unrelated to patient care. Examples of time-based services typically provided by hospitalists include:

Critical-care services (CPT codes 99291-99292);

Hospital discharge day management (CPT codes 99238-99239);

E/M codes in which counseling and/or coordination of care dominates (more than 50% of) the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service; and

Prolonged services (CPT codes 99358-99359).

Surgical Services

Surgical services, which are defined as minor or major, also are subject to teaching physician rules. Teaching physician regulations identify minor procedures as those that take five minutes or less to complete and involve relatively little decision making once the need for the service is determined. Appropriate billing and payment hinges on the teaching physician’s presence for the entire procedure. Documentation should include a statement of presence, written and signed by the teaching physician.

Services that require more than five minutes are considered major surgical services, requiring teaching physician presence only during the (physician-determined) critical and key portions of the procedure. However, the teaching physician must be available to return to the procedure area during the surgery’s entirety, and not be involved in another procedure. Arrangements must be made to have another qualified physician available should the teaching physician get called away. 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.

References:

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

2. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2, www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.

3. Centers for Medicare & Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents, www.cms.hhs.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf.

4. Manaker, S. Teaching Physician Regulations. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008; 279-285.

5. Pohlig, C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008;57-69.

6. American Medical Association. cpt® 2008, Current Procedural Terminology Professional Edition. American Medical Association, 2007; 9-16.

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This article will focus on the documentation guidelines for inpatient services provided by the hospitalist in a teaching setting.

Evaluation and Management Services

Teaching physicians participate in evaluation and management (E/M) services with residents in several different ways. Below, three scenarios discuss documentation requirements:

Code This Case

the solution

When referencing resident documentation, the teaching physician should use Medicare-approved linkage statements. Common examples include the following:

“I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

“I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”

“I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder than documented, so I will obtain an echo to evaluate.”

Although all of these examples are acceptable, the last one best identifies the teaching physician’s involvement in patient management, which is a requirement of TP documentation.

Medicare Definitions for Teaching Services

Critical or Key Portion: The part, or parts, of a service the teaching physician determines are critical or key. For purposes of this section, these terms are interchangeable.

Direct Medical and Surgical Services: To individual beneficiaries that are either furnished by a physician or by a resident under the supervision of a physician in a teaching hospital.

Teaching Hospital: A hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry or podiatry.

Teaching Physician: A physician (other than a resident) who involves residents in the care of his or her patients.

Teaching Setting: Any setting in which the FI makes Medicare payments for the services of residents under the direct graduate medical education payment methodology.

Teaching physician statements associated with scenario two and accepted by Medicare reviewers include the following:

“I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”

“I saw the patient with the resident and agree with the resident’s findings and plan.”

Medicare-approved linkage statements for use by teaching physicians in this scenario include the following:

“I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”

“I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”

“See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”

“I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

“Agree with above,” followed by legible countersignature or identity;

“Rounded, Reviewed, Agree,” followed by legible countersignature or identity;

“Discussed with resident. Agree,” followed by legible countersignature or identity;

“Seen and agree,” followed by legible countersignature or identity;

“Patient seen and evaluated,” followed by legible countersignature or identity; and

Legible countersignature or identity alone.

Time-Based Services

Critical-care services (CPT codes 99291-99292);

Hospital discharge day management (CPT codes 99238-99239);

E/M codes in which counseling and/or coordination of care dominates (more than 50% of) the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service; and

Prolonged services (CPT codes 99358-99359).

Surgical Services

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.

References:

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

2. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2, www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.

3. Centers for Medicare & Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents, www.cms.hhs.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf.

4. Manaker, S. Teaching Physician Regulations. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008; 279-285.

5. Pohlig, C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008;57-69.

6. American Medical Association. cpt® 2008, Current Procedural Terminology Professional Edition. American Medical Association, 2007; 9-16.

This article will focus on the documentation guidelines for inpatient services provided by the hospitalist in a teaching setting.

Evaluation and Management Services

Teaching physicians participate in evaluation and management (E/M) services with residents in several different ways. Below, three scenarios discuss documentation requirements:

Code This Case

the solution

When referencing resident documentation, the teaching physician should use Medicare-approved linkage statements. Common examples include the following:

“I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

“I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”

“I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder than documented, so I will obtain an echo to evaluate.”

Although all of these examples are acceptable, the last one best identifies the teaching physician’s involvement in patient management, which is a requirement of TP documentation.

Medicare Definitions for Teaching Services

Critical or Key Portion: The part, or parts, of a service the teaching physician determines are critical or key. For purposes of this section, these terms are interchangeable.

Direct Medical and Surgical Services: To individual beneficiaries that are either furnished by a physician or by a resident under the supervision of a physician in a teaching hospital.

Teaching Hospital: A hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry or podiatry.

Teaching Physician: A physician (other than a resident) who involves residents in the care of his or her patients.

Teaching Setting: Any setting in which the FI makes Medicare payments for the services of residents under the direct graduate medical education payment methodology.

Teaching physician statements associated with scenario two and accepted by Medicare reviewers include the following:

“I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”

“I saw the patient with the resident and agree with the resident’s findings and plan.”

Medicare-approved linkage statements for use by teaching physicians in this scenario include the following:

“I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”

“I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”

“See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”

“I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

“Agree with above,” followed by legible countersignature or identity;

“Rounded, Reviewed, Agree,” followed by legible countersignature or identity;

“Discussed with resident. Agree,” followed by legible countersignature or identity;

“Seen and agree,” followed by legible countersignature or identity;

“Patient seen and evaluated,” followed by legible countersignature or identity; and

Legible countersignature or identity alone.

Time-Based Services

Critical-care services (CPT codes 99291-99292);

Hospital discharge day management (CPT codes 99238-99239);

E/M codes in which counseling and/or coordination of care dominates (more than 50% of) the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service; and

Prolonged services (CPT codes 99358-99359).

Surgical Services

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.

References:

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

2. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2, www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.

3. Centers for Medicare & Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents, www.cms.hhs.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf.

4. Manaker, S. Teaching Physician Regulations. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008; 279-285.

5. Pohlig, C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008;57-69.

6. American Medical Association. cpt® 2008, Current Procedural Terminology Professional Edition. American Medical Association, 2007; 9-16.

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The Observation Deck

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The Observation Deck

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Carol Pohlig

Observation care provides a mechanism to evaluate and treat patients without the resource utilization and financial responsibility associated with an inpatient admission. Hospitalists may not understand the billing compliance risk and corresponding revenue implications when observation services (OBS) are not captured correctly.

Are OBS best reported with observation care codes (99218-99220, 99234-99236), office visit codes (99201-99215), or initial hospital care codes (99221-99223)? Code selection depends upon the patient’s registered status, the nature of the provided service, and the length of stay. Review the following information before reporting OBS to ensure an accurate claim submission.

Code This Case

The hospitalist orders an inpatient admission. Somewhere along the stay, the status was changed to OBS. Does the hospitalist report observation care codes or inpatient service codes?

In cases where a hospital utilization review committee determines an inpatient admission does not meet the hospital’s inpatient criteria, the hospital may change the patient status from inpatient to outpatient. They then submit an outpatient claim for medically necessary services that were furnished, as long as the following Medicare requirements are met:

The patient status change is made prior to patient discharge;

The hospital has not submitted a claim to Medicare for the inpatient admission;

A physician concurs with the utilization review committee’s decision; and

The physician’s concurrence with the utilization review committee’s decision is documented in the patient’s medical record.6

The entire stay is treated as observation, and physicians report the observation care codes—as appropriate non-Medicare insurer guidelines may vary but often follow Medicare guidelines. It is best to query non-Medicare payers for their specific change-of-status policies.

Attending Physician Responsibilities

The physician-documented reason for observation substantiates the medical necessity for the OBS admission. Contractors often evaluate medical records to determine the consistency between the physician order (physician intent), the services actually provided (inpatient or outpatient), and the medical necessity of those services, including the medical appropriateness of the inpatient or observation stay.

Certain diagnoses and procedures generally do not support an inpatient admission and fall within the definitions of outpatient observation. Uncomplicated presentations of chest pain (rule out MI), mild asthma/COPD, mild CHF, syncope and decreased responsiveness, atrial arrhythmias, and renal colic all frequently are associated with the expectation of a brief (less than 24-hour) stay unless serious pathology is uncovered.2 Situations that do not meet the criteria for observation care are considered “not medically necessary” and separate payment is not permitted. Examples of circumstances that lack medical necessity include:

Outpatient blood administration;

Lack of/delay in patient transportation;

Provision of a medical exam for patients who do not require skilled support;

Routine preparation prior to and recovery after diagnostic testing;

Routine recovery and post-operative care after ambulatory surgery;

When used for the convenience of the physician, patient or patient’s family;

While awaiting transfer to another facility;

Duration of care exceeding 48 hours;

When an overnight stay is planned prior to diagnostic testing;

Standing orders following outpatient surgery;

Services that would normally require inpatient stay;

No physicians order to admit to observation;

Observation following an uncomplicated treatment or procedure;

Services that are not reasonable and necessary for care of the patient;

Services provided concurrently with chemotherapy; and

Inpatients discharged to outpatient observation status.3

The attending physician of record assumes responsibility for the patient’s admission to observation and is permitted to report observation care codes. In addition to the reason for admission, a medical record involving the observation stay must include dated and timed physician admitting orders outlining the care plan, physician progress notes, and discharge orders. This documentation must be added to any other record prepared as a result of an emergency department or outpatient clinic encounter. If physicians other than the admitting physician/group (i.e., physicians in different specialties) provide services to the patient during observation, they must use the appropriate outpatient visit (e.g., 99214) or consultation code (e.g., 99244).

Length of Stay⁴

In general, the duration of observation care services typically does not exceed 24 hours, although in some circumstances patients may require a second day. Observation care for greater than 48 hours without inpatient admission is not considered medically necessary but may be payable after medical review. When the stay spans two calendar days, physician billing is straightforward: Select an initial observation care code (99218-99220) for calendar day one and the observation discharge code (99217) for day two. Only the admitting physician/group may report the discharge service, when applicable. Documentation must demonstrate a face-to-face encounter by the physician for each date of service.

Should the stay only constitute one calendar day, the duration of care becomes a crucial factor in determining the code category. Standard OBS codes (99218-99220) are applicable if the patient stay is less than eight hours on any given date. The OBS discharge code (99217) is not reported in this instance, although the documentation should reflect the attending physician’s written order and appropriate discharge plan. Alternately, same day admit/discharge codes (99234-99236) apply to single-day stays lasting more than eight hours. The OBS discharge code (99217) also is not reported in this instance. Documentation must identify, at a minimum:

Duration of the stay;

Presence by the billing physician; and

Physician performance of each service (i.e., both an admission and discharge note).

Inpatient Admission^1,4-5

Sometimes the patient requires inpatient admission after initially being placed in observation. If the inpatient admission occurs on the same day as the OBS admission, only one service is reported (e.g., 99222). The physician need not redocument a complete history and physical (H&P) but merely write the new order for admission and update the OBS assessment with any relevant, new information.

Should the inpatient admission occur on the second calendar day of the OBS stay, the physician is able to report the initial observation care code (e.g., 99219) on day one, and the initial inpatient care code (e.g., 99223) on day two. However, the physician must meet the documentation guidelines for initial hospital care and redocument the H&P associated with the reported visit level. In the case of 99223, the physician must document a comprehensive history (only referring to the previous review of systems and histories, while rewriting the history of present illness) and high complexity decision making. If the physician chooses not to document to this extent, a subsequent hospital care code (99231-99233) is reasonable because the episode of care is a continuation from the observation phase.

Beware that some insurers may change the patient’s status for the entire episode of care. In other words, the conversion to inpatient status occurs on day two of the patient stay, but the insurer may convert the entire stay, including day one, to an inpatient status. Should this happen, the physician is responsible for reporting the visit category that corresponds with the patient’s status. Inpatient services codes are required for claim submission when the patient stay qualifies as an inpatient admission. Because these conversions occur with some frequency, it is advisable to hold claims intended for observation patients until the correct patient status can be confirmed by the utilization review team, and communicated to the physician. 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.

Code of the Month: Observation Care¹

99218: Initial observation care, per day, for patient evaluation and management requiring:

A detailed or comprehensive history;

A detailed or comprehensive examination; and

Medical decision making that is straightforward or of low complexity.

Usually, the problem(s) requiring admission to “observation status” are of low severity.

99219: Initial observation care, per day, for patient evaluation and management requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of moderate complexity.

Usually, the problem(s) requiring admission to “observation status” are of moderate severity.

99220: Initial observation care, per day, for patient evaluation and management requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of high complexity.

Usually, the problem(s) requiring admission to “observation status” are of high severity.

99217: Observation care discharge day management

99234: Observation or inpatient care for patient evaluation and management, including admission and discharge on the same date, requiring:

A detailed or comprehensive history;

A detailed or comprehensive examination; and

Medical decision making that is straightforward or of low complexity.

Usually the presenting problem(s) requiring admission are of low severity.

99235: Observation or inpatient care for patient evaluation and management, including admission and discharge on the same date, requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of moderate complexity.

Usually the presenting problem(s) requiring admission are of moderate severity.

99236: Observation or inpatient care for patient evaluation and management, including admission and discharge on the same date, requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of high complexity.

Usually the presenting problem(s) requiring admission are of high severity.

References

1. American Medical Association. cpt 2008, Current Procedural Terminology Professional Edition. Chicago, IL: American Medical Association, 2007; 9-16 CPT codes, descriptions and other data only are copyright 2007 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

2. Highmark Medicare Services. Local Coverage Determination L27548 Acute Care: Inpatient, Observation and Treatment Room Services. Available at www.highmarkmedicareservices.com/policy/mac-ab/127548.html. Accessed July 14, 2008.

3. Cigna. Healthcare Coverage Position: Observation Care. Available at www.cigna.com/customer_care/healthcare_ professional/coverage_positions/medical/mm_0411_coveragepositioncriteria_observation_care.pdf. Accessed July 12, 2008.

4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at www.cms.hhs.gov/manuals/downloads/ clm104c12.pdf. Accessed July 13, 2008.

5. Pohlig C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 57-69.

6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 1, Section 50.3. Available at www.cms.hhs.gov/manuals/downloads/ clm104c01.pdf. Accessed July 13, 2008.

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Code This Case

The hospitalist orders an inpatient admission. Somewhere along the stay, the status was changed to OBS. Does the hospitalist report observation care codes or inpatient service codes?

The patient status change is made prior to patient discharge;

The hospital has not submitted a claim to Medicare for the inpatient admission;

A physician concurs with the utilization review committee’s decision; and

The physician’s concurrence with the utilization review committee’s decision is documented in the patient’s medical record.6

Attending Physician Responsibilities

Outpatient blood administration;

Lack of/delay in patient transportation;

Provision of a medical exam for patients who do not require skilled support;

Routine preparation prior to and recovery after diagnostic testing;

Routine recovery and post-operative care after ambulatory surgery;

When used for the convenience of the physician, patient or patient’s family;

While awaiting transfer to another facility;

Duration of care exceeding 48 hours;

When an overnight stay is planned prior to diagnostic testing;

Standing orders following outpatient surgery;

Services that would normally require inpatient stay;

No physicians order to admit to observation;

Observation following an uncomplicated treatment or procedure;

Services that are not reasonable and necessary for care of the patient;

Services provided concurrently with chemotherapy; and

Inpatients discharged to outpatient observation status.3

Length of Stay⁴

Duration of the stay;

Presence by the billing physician; and

Physician performance of each service (i.e., both an admission and discharge note).

Inpatient Admission^1,4-5

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 of the Month: Observation Care¹

99218: Initial observation care, per day, for patient evaluation and management requiring:

A detailed or comprehensive history;

A detailed or comprehensive examination; and

Medical decision making that is straightforward or of low complexity.

Usually, the problem(s) requiring admission to “observation status” are of low severity.

99219: Initial observation care, per day, for patient evaluation and management requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of moderate complexity.

Usually, the problem(s) requiring admission to “observation status” are of moderate severity.

99220: Initial observation care, per day, for patient evaluation and management requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of high complexity.

Usually, the problem(s) requiring admission to “observation status” are of high severity.

99217: Observation care discharge day management

99234: Observation or inpatient care for patient evaluation and management, including admission and discharge on the same date, requiring:

A detailed or comprehensive history;

A detailed or comprehensive examination; and

Medical decision making that is straightforward or of low complexity.

Usually the presenting problem(s) requiring admission are of low severity.

99235: Observation or inpatient care for patient evaluation and management, including admission and discharge on the same date, requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of moderate complexity.

Usually the presenting problem(s) requiring admission are of moderate severity.

99236: Observation or inpatient care for patient evaluation and management, including admission and discharge on the same date, requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of high complexity.

Usually the presenting problem(s) requiring admission are of high severity.

References

1. American Medical Association. cpt 2008, Current Procedural Terminology Professional Edition. Chicago, IL: American Medical Association, 2007; 9-16 CPT codes, descriptions and other data only are copyright 2007 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

2. Highmark Medicare Services. Local Coverage Determination L27548 Acute Care: Inpatient, Observation and Treatment Room Services. Available at www.highmarkmedicareservices.com/policy/mac-ab/127548.html. Accessed July 14, 2008.

3. Cigna. Healthcare Coverage Position: Observation Care. Available at www.cigna.com/customer_care/healthcare_ professional/coverage_positions/medical/mm_0411_coveragepositioncriteria_observation_care.pdf. Accessed July 12, 2008.

4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at www.cms.hhs.gov/manuals/downloads/ clm104c12.pdf. Accessed July 13, 2008.

5. Pohlig C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 57-69.

6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 1, Section 50.3. Available at www.cms.hhs.gov/manuals/downloads/ clm104c01.pdf. Accessed July 13, 2008.

Code This Case

The hospitalist orders an inpatient admission. Somewhere along the stay, the status was changed to OBS. Does the hospitalist report observation care codes or inpatient service codes?

The patient status change is made prior to patient discharge;

The hospital has not submitted a claim to Medicare for the inpatient admission;

A physician concurs with the utilization review committee’s decision; and

The physician’s concurrence with the utilization review committee’s decision is documented in the patient’s medical record.6

Attending Physician Responsibilities

Outpatient blood administration;

Lack of/delay in patient transportation;

Provision of a medical exam for patients who do not require skilled support;

Routine preparation prior to and recovery after diagnostic testing;

Routine recovery and post-operative care after ambulatory surgery;

When used for the convenience of the physician, patient or patient’s family;

While awaiting transfer to another facility;

Duration of care exceeding 48 hours;

When an overnight stay is planned prior to diagnostic testing;

Standing orders following outpatient surgery;

Services that would normally require inpatient stay;

No physicians order to admit to observation;

Observation following an uncomplicated treatment or procedure;

Services that are not reasonable and necessary for care of the patient;

Services provided concurrently with chemotherapy; and

Inpatients discharged to outpatient observation status.3

Length of Stay⁴

Duration of the stay;

Presence by the billing physician; and

Physician performance of each service (i.e., both an admission and discharge note).

Inpatient Admission^1,4-5

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 of the Month: Observation Care¹

99218: Initial observation care, per day, for patient evaluation and management requiring:

A detailed or comprehensive history;

A detailed or comprehensive examination; and

Medical decision making that is straightforward or of low complexity.

Usually, the problem(s) requiring admission to “observation status” are of low severity.

99219: Initial observation care, per day, for patient evaluation and management requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of moderate complexity.

Usually, the problem(s) requiring admission to “observation status” are of moderate severity.

99220: Initial observation care, per day, for patient evaluation and management requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of high complexity.

Usually, the problem(s) requiring admission to “observation status” are of high severity.

99217: Observation care discharge day management

99234: Observation or inpatient care for patient evaluation and management, including admission and discharge on the same date, requiring:

A detailed or comprehensive history;

A detailed or comprehensive examination; and

Medical decision making that is straightforward or of low complexity.

Usually the presenting problem(s) requiring admission are of low severity.

99235: Observation or inpatient care for patient evaluation and management, including admission and discharge on the same date, requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of moderate complexity.

Usually the presenting problem(s) requiring admission are of moderate severity.

99236: Observation or inpatient care for patient evaluation and management, including admission and discharge on the same date, requiring:

A comprehensive history;

A comprehensive examination; and

Medical decision making of high complexity.

Usually the presenting problem(s) requiring admission are of high severity.

References

1. American Medical Association. cpt 2008, Current Procedural Terminology Professional Edition. Chicago, IL: American Medical Association, 2007; 9-16 CPT codes, descriptions and other data only are copyright 2007 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

2. Highmark Medicare Services. Local Coverage Determination L27548 Acute Care: Inpatient, Observation and Treatment Room Services. Available at www.highmarkmedicareservices.com/policy/mac-ab/127548.html. Accessed July 14, 2008.

3. Cigna. Healthcare Coverage Position: Observation Care. Available at www.cigna.com/customer_care/healthcare_ professional/coverage_positions/medical/mm_0411_coveragepositioncriteria_observation_care.pdf. Accessed July 12, 2008.

4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at www.cms.hhs.gov/manuals/downloads/ clm104c12.pdf. Accessed July 13, 2008.

5. Pohlig C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 57-69.

6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 1, Section 50.3. Available at www.cms.hhs.gov/manuals/downloads/ clm104c01.pdf. Accessed July 13, 2008.

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Sort Out Surgical Cases

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Sort Out Surgical Cases

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Carol Pohlig

Hospitalists often are involved in the care of a surgical patient. Reimbursement for surgical procedures includes payment for pre-, intra-, and post-operative care.

Knowing the billing and coding responsibilities apart from those of the surgeon is imperative for the hospitalist’s accurate charge capture. There are several critical misconceptions in this regard:

Hospitalists cannot bill for services when involved in a surgical case;

Surgeons are not responsible for inpatient care if the patient is stable and does not require additional inpatient post-op visits; and

Modifiers are not required for hospitalist claims unless the hospitalist reports under the same tax identification number as the surgeon.

Determine Global Period

Procedures are categorized as major or minor surgery. A global period is assigned to each procedure code, designating post-operative periods of zero, 10, or 90 days. Physician services during this global period are considered part of the packaged payment and not separately reimbursed.

The global period for any given CPT code can be identified in the Medicare Physician Fee Schedule and accessed at www.cms.hhs.gov/PfsLookup. In addition to zero, 10, and 90 days, services can be noted with:

XXX, indicating the global period concept does not apply; or

ZZZ, indicating an “add-on” procedure that must always be reported with the relevant primary procedure code; “add-on” procedures assume the global period of the primary procedure.

Major surgery routinely is allotted 90-day global periods. Therefore, the surgeon is responsible for the patient and must provide all related care one day prior to the surgery forward thru 90 postoperative days at no additional charge. Minor surgery, including endoscopy, has zero or 10-day postoperative periods, bundling all services on the surgical day only, or the surgical day and the subsequent 10 days, respectively (see Table 1, p. above).

The Surgeon Defined

Any qualified physician able to perform “surgical” services within his scope of practice is considered a “surgeon” for billing purposes. For example, a pulmonologist, or primary care physician, must meet the surgical billing and documentation requirements when performing bronchoscopies or uncomplicated incision-and-drainage services, respectively.

Surgical services easily are identified as any code included in range 20000-69999. This code series includes major, minor, and endoscopic procedures. The “surgeon” and all physicians in the same group practice (i.e., reporting services under the same tax identification number) with the same specialty designation must adhere to the global period billing rules.

Alternately, physicians with different specialty designations in the same group practice (e.g., multispecialty group that reports services under the same tax identification number) or different group practices can perform and separately report medically necessary services during the surgeon’s global period, as long as a formal (mutually agreed upon) transfer of care did not occur. Information on physician specialty designations is available at www.highmarkmedicareservices.com/partb/refman/appendix-d.html.

Key Modifiers

25: Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.

A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Report this modifier with separately identifiable visits provided on the same day as minor surgical procedures, or endoscopies.

57: Decision for Surgery. An evaluation and management service that resulted in the initial decision to perform the [major] surgery may be identified by adding the modifier 57 to the appropriate level of E/M service. Decisions for elective surgeries are typically made at a previous outpatient encounter. Do not append modifier 57 when this occurs.

24: Unrelated E/M service by the same physician during a postoperative period. The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier 24 to the appropriate level of E/M service.

Modifier 24 is not recognized when appended to postoperative visits provided during the same hospitalization in which the surgery occurred. Append modifier 24 to all unrelated outpatient care, post-discharge, or inpatient care during readmissions within the designated global period. Modifier 24 is only used for visits associated with 10- or 90-day postoperative periods.—CP

Package Components

The following services are included in the surgeon’s packaged payment:

Preoperative visits after the decision for surgery is made beginning one day prior to surgery;

All additional post-operative medical or surgical services provided by the surgeon related to complications, but not require additional trips to the operating room;

Post-operative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and

Post-operative pain management provided by the surgeon.

Services not included are:

The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Append modifier 57 to this visit if provided the day before or day of major surgery to alert the payer that the service resulted in the decision for surgery. Append modifier 25 to this visit if provided the day of minor surgery;

Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;

Post-operative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery. These services only are payable after the patient has been discharged from the hospitalization in which the surgery occurred. Append modifier 24 to these unrelated post-op visits;

Diagnostic tests and procedures, including diagnostic radiological procedures;

Clearly distinct surgical procedures during the post-operative period that do not result in repeat operations or treatment for complications;

Treatment for post-operative complications that require a return trip to the operating room, catheterization lab, or endoscopy suite;

Immunosuppressive therapy for organ transplants; and

Critical care services (CPT codes 99291 and 99292) unrelated to the surgery in which a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon. Append modifier 24 to these unrelated critical care services (see Table 2, above).

Payer Variations

While Medicare does not require modifier usage by hospitalists providing medically necessary services on surgical cases, some private payers do. Their electronic claim systems may not differentiate services by non-surgical specialists, requiring all physicians to append the appropriate modifier depending on the reason and timing of the service (see “Key Modifiers” below). 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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Hospitalists often are involved in the care of a surgical patient. Reimbursement for surgical procedures includes payment for pre-, intra-, and post-operative care.

Hospitalists cannot bill for services when involved in a surgical case;

Surgeons are not responsible for inpatient care if the patient is stable and does not require additional inpatient post-op visits; and

Modifiers are not required for hospitalist claims unless the hospitalist reports under the same tax identification number as the surgeon.

Determine Global Period

XXX, indicating the global period concept does not apply; or

ZZZ, indicating an “add-on” procedure that must always be reported with the relevant primary procedure code; “add-on” procedures assume the global period of the primary procedure.

The Surgeon Defined

Key Modifiers

Package Components

The following services are included in the surgeon’s packaged payment:

Preoperative visits after the decision for surgery is made beginning one day prior to surgery;

All additional post-operative medical or surgical services provided by the surgeon related to complications, but not require additional trips to the operating room;

Post-operative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and

Post-operative pain management provided by the surgeon.

Services not included are:

The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Append modifier 57 to this visit if provided the day before or day of major surgery to alert the payer that the service resulted in the decision for surgery. Append modifier 25 to this visit if provided the day of minor surgery;

Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;

Post-operative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery. These services only are payable after the patient has been discharged from the hospitalization in which the surgery occurred. Append modifier 24 to these unrelated post-op visits;

Diagnostic tests and procedures, including diagnostic radiological procedures;

Clearly distinct surgical procedures during the post-operative period that do not result in repeat operations or treatment for complications;

Treatment for post-operative complications that require a return trip to the operating room, catheterization lab, or endoscopy suite;

Immunosuppressive therapy for organ transplants; and

Critical care services (CPT codes 99291 and 99292) unrelated to the surgery in which a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon. Append modifier 24 to these unrelated critical care services (see Table 2, above).

Payer Variations

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.

Hospitalists often are involved in the care of a surgical patient. Reimbursement for surgical procedures includes payment for pre-, intra-, and post-operative care.

Hospitalists cannot bill for services when involved in a surgical case;

Surgeons are not responsible for inpatient care if the patient is stable and does not require additional inpatient post-op visits; and

Modifiers are not required for hospitalist claims unless the hospitalist reports under the same tax identification number as the surgeon.

Determine Global Period

XXX, indicating the global period concept does not apply; or

ZZZ, indicating an “add-on” procedure that must always be reported with the relevant primary procedure code; “add-on” procedures assume the global period of the primary procedure.

The Surgeon Defined

Key Modifiers

Package Components

The following services are included in the surgeon’s packaged payment:

Preoperative visits after the decision for surgery is made beginning one day prior to surgery;

All additional post-operative medical or surgical services provided by the surgeon related to complications, but not require additional trips to the operating room;

Post-operative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and

Post-operative pain management provided by the surgeon.

Services not included are:

The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Append modifier 57 to this visit if provided the day before or day of major surgery to alert the payer that the service resulted in the decision for surgery. Append modifier 25 to this visit if provided the day of minor surgery;

Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;

Post-operative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery. These services only are payable after the patient has been discharged from the hospitalization in which the surgery occurred. Append modifier 24 to these unrelated post-op visits;

Diagnostic tests and procedures, including diagnostic radiological procedures;

Clearly distinct surgical procedures during the post-operative period that do not result in repeat operations or treatment for complications;

Treatment for post-operative complications that require a return trip to the operating room, catheterization lab, or endoscopy suite;

Immunosuppressive therapy for organ transplants; and

Critical care services (CPT codes 99291 and 99292) unrelated to the surgery in which a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon. Append modifier 24 to these unrelated critical care services (see Table 2, above).

Payer Variations

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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Bill by Time Spent on Case

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Bill by Time Spent on Case

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Carol Pohlig

In my recent columns, I addressed documentation guidelines with respect to the three key components: history, exam, and medical decision-making. However, time is considered the fourth key component.

Time-based billing places significant emphasis on the duration of the hospitalist-patient encounter more so than the detail or quality of the documentation. This month, I’ll focus on the guidelines for reporting inpatient hospital services based on time.

Code This Case

A newly diagnosed diabetic requires extensive counseling regarding lifestyle changes, medication regime, the disease process as well as coordination of care for outpatient programs and services. The hospitalist reviews some of the pertinent information with the patient (15 minutes) and asks the resident to assist him with the remaining counseling efforts and coordination of care (25 minutes). Each document their portion of the service? What visit level can the hospitalist report?

The Solution

The billing provider’s time counts. In this instance the attending physician accumulated 15 minutes of time, equivalent to 99231 (subsequent hospital care). However, if the physician obtained and documented history or exam, in addition to the medical decision-making and counseling portion, a higher visit level may be reported if appropriate.

Counseling, Coordination

Hospitalists try to make their rounds as efficient as possible while still upholding a high standard of care. It is not unusual for a patient encounter to vary from the norm of updating the history, performing the necessary exam, and implementing the plan.

In fact, hospitalists often counsel patients with newly diagnosed conditions or when treatment options seem extensive and complicated. Based on these circumstances, physicians can document only a brief history and exam or none at all, since the bulk of the encounter focuses on medical decision-making, counseling, and coordination of care. Despite the minimal documentation compared with other physician services, it still is possible to report something more than the lowest service level (e.g., subsequent hospital care, 99231).

To use time as the determining factor for the visit level, more than 50% of the total visit time must involve counseling/coordination of care. The total visit time encompasses both the face-to-face time spent with the patient at the bedside and the additional time spent on the unit/floor reviewing data, obtaining relevant patient information, and discussing the case with other involved healthcare providers. Physicians providing care in academic settings cannot contribute teaching time toward the total visit time. Further, only the attending physician’s time counts.

Code of the Month

Counseling/Coordination of Care

Total visit times are used for selecting the visit level only when the majority of the patient encounter involves counseling and/or coordination of care. It is not to be used for determining the visit level when counseling/coordination of care is minimal or absent from the patient encounter. Inpatient visit times reflect the counseling/coordination of care time spent on the hospital unit/floor by the billing provider.

Total Visit Times (Minutes)

Initial Hospital Care

99221 30

99222 50

99223 70

Subsequent Hospital Care

99231 15

99232 25

99233 35

Inpatient Consultations

99251 20

99252 40

99253 55

99254 80

99255 110

Documentation

Hospitalists must document events during the patient encounter. There may be little or no history and an exam and counseling may dominate the entire visit.

Physicians must document both the counseling/coordination of care time and total visit time. The format may vary: “Total visit time = 25 minutes; more than 50% spent counseling/coordinating care,” or “20 of 25 minutes spent counseling/coordinating care.” Any given payer may prefer one documentation style over another. It always is best to query payers and review their documentation standards to determine the local preference.

In addition to the time, physicians must document the medical decision-making and details of the counseling/coordination of care. For example, patients with newly diagnosed diabetes need to be educated about their condition, lifestyle, and medication requirements. Physicians should include information regarding these factors in their progress notes as necessary.

Family Discussions

As noted in my previous article on critical care services (March 2008, p. 18), family discussions can contribute toward counseling/coordination of care 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; or

The conversation bears directly on the management of the patient.

Prolonged Care

A physician makes his rounds in the morning. He cares for a 72-year-old female with diabetes, end-stage renal disease, and hypertension. In the afternoon, he returns to find the family waiting with questions. He spends an additional 30 minutes speaking at the bedside with the patient and family. The additional afternoon effort may be captured as prolonged care if both services are documented appropriately.

For inpatient services, CPT defines code 99356 as the first hour of prolonged physician services requiring face-to-face patient contact beyond the usual services (reportable after the initial 30 minutes). Code 99357 is used for each additional 30 minutes of prolonged care beyond the first hour (reportable after the first 15 minutes of each additional segment). Both codes are considered add-on codes and cannot be reported alone on a claim form; a primary code must be reported. Code 99357 must be used with 99356, and 99356 must be reported with one of the following inpatient service [primary] codes: 99221-99223, 99231-99233, or 99251-99255.

Prolonged care employs the concept of threshold time. This means total face-to-face physician visit time must exceed the time requirements associated with the primary codes by 30 minutes (e.g., 99232 plus 99356 = 25 minutes plus 30 minutes = 55 total face-to-face attending visit minutes). Accordingly, the physician must document the total face-to-face time spent during each portion of care in two separate notes or in one cumulative note. Be aware that this varies from the standard reporting of counseling and/or coordination of care time in that the physician must meet the threshold face-to-face-time requirements (see Table 1, left), making prolonged care services inefficient. When two providers from the same group practice split the threshold time (e.g., physician A provided morning rounds, and physician B spoke with the family in the afternoon), only one physician can report the cumulative service. To reiterate, 99356 must be reported on the same invoice as the primary visit code (e.g., 99232). Be sure once again to query payers, because most non-Medicare insurers do not recognize these codes. 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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In my recent columns, I addressed documentation guidelines with respect to the three key components: history, exam, and medical decision-making. However, time is considered the fourth key component.

Code This Case

The Solution

Counseling, Coordination

Code of the Month

Counseling/Coordination of Care

Total Visit Times (Minutes)

Initial Hospital Care

99221 30

99222 50

99223 70

Subsequent Hospital Care

99231 15

99232 25

99233 35

Inpatient Consultations

99251 20

99252 40

99253 55

99254 80

99255 110

Documentation

Hospitalists must document events during the patient encounter. There may be little or no history and an exam and counseling may dominate the entire visit.

Family Discussions

As noted in my previous article on critical care services (March 2008, p. 18), family discussions can contribute toward counseling/coordination of care 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; or

The conversation bears directly on the management of the patient.

Prolonged Care

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.

In my recent columns, I addressed documentation guidelines with respect to the three key components: history, exam, and medical decision-making. However, time is considered the fourth key component.

Code This Case

The Solution

Counseling, Coordination

Code of the Month

Counseling/Coordination of Care

Total Visit Times (Minutes)

Initial Hospital Care

99221 30

99222 50

99223 70

Subsequent Hospital Care

99231 15

99232 25

99233 35

Inpatient Consultations

99251 20

99252 40

99253 55

99254 80

99255 110

Documentation

Hospitalists must document events during the patient encounter. There may be little or no history and an exam and counseling may dominate the entire visit.

Family Discussions

As noted in my previous article on critical care services (March 2008, p. 18), family discussions can contribute toward counseling/coordination of care 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; or

The conversation bears directly on the management of the patient.

Prolonged Care

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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Document Your Decisions

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Carol Pohlig

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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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.

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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Carol Pohlig

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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Document Patient History

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Carol Pohlig

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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Report Critical Care

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Report Critical Care

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Carol Pohlig

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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Carol Pohlig

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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Daily Care Conundrums

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Carol Pohlig

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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Evaluation and Management Services

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Inpatient Admission1,4-5

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Inpatient Admission1,4-5

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Counseling, Coordination

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Counseling, Coordination

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Inpatient Admission^1,4-5

Code of the Month: Observation Care¹

Length of Stay⁴

Inpatient Admission^1,4-5

Code of the Month: Observation Care¹

Length of Stay⁴

Inpatient Admission^1,4-5

Code of the Month: Observation Care¹