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Inpatient Coding Strategies
American College of PhysiciansMarch 1, 2013
Jaci JohnsonCPC,CPMA,CEMC,CPC-H,CPC-I
President, Practice Integrity, [email protected]
Disclaimer
Information contained in this text is based on CPT®, ICD-9-CM and HCPCS rules and regulations. However, application of the information in this text does not guarantee claims payment. Payers’ interpretation may vary from those found in this text. Please note that the law, applicable regulations, payer’ instructions, interpretations, enforcement, etc., may change at any time. Therefore, it is crucial to stay current with all local and national regulations and policies.
Evaluation and Management
READ THE GUIDELINES – Medicare Documentation GuidelinesGENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATIONThe principles of documentation listed below are applicable to all types of medical and surgical services in all settings.For Evaluation and Management (E/M) services,the nature and amount of physician work and documentation varies bytype of service, place of service and the patient's status.The general principles listed below may be modified to account for these variable circumstances in providing E/M services.
Evaluation and Management
READ THE GUIDELINES – Medicare Documentation GuidelinesThe medical record should be complete and legible.The documentation of each patient encounter should include:reason for the encounter and relevant history, physical examinationfindings and prior diagnostic test results;assessment, clinical impression or diagnosis;plan for care; anddate and legible identity of the observer.
Evaluation and Management
READ THE GUIDELINES – Medicare Documentation GuidelinesIf not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.Past and present diagnoses should be accessible to the treating and/or consulting physician.Appropriate health risk factors should be identified.
Evaluation and Management
READ THE GUIDELINES – Medicare Documentation Guidelines6.The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.
Evaluation and Management
READ THE GUIDELINES – Medicare Documentation Guidelines8.The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
Evaluation and Management
READ THE GUIDELINES –OIG CompliancePolicy for Physician PracticesMedical Record Documentation. In addition to facilitating high quality patient care, a properly documented medical record verifies and documents precisely what services were actually provided.The medical record may be used to validate: (a) The site of the service; (b) the appropriateness of the services provided; (c) the accuracy of the billing; and (d) the identity of the care giver (service provider).
Evaluation and Management ServicesCredit for Work Done
Coding Based on TimeUnit/floor TimeIf over 50% of the floor/unit time is spent in counseling and coordination of care then time may be used as the indicator for the code selection.Hospital observation, inpatient hospital, inpatient consultations, nursing facilityNOT DOCUMENTED NOT DONE
Evaluation and Management Services
Hospital ServicesChoosing the correct level of service is important in hospital setting also.
Hospital Charges
How are they tracked/followed?Does the diagnosis tell your part of the story?Do you provide the patient information from the hospital for your staff.
Evaluation and Management Services
Hospital admission (99221 – 99223)Code selection based onlevel of service or timeDo not bill for other related E&M services onsame dateof admissionDescribes the first inpatient encounter with the patient.
Evaluation and Management Services
99221 (30 minutes)Detailed or comprehensive history and examStraightforward or Low level Medical Decision Making99222 (50 minutes)Comprehensive History and ExamModerate level Medical Decision Making99223 (70 minutes)Comprehensive History and ExamHigh level Medical Decision Making
Subsequent Hospital Visits
99231, 99232, 99233Every note stands aloneWhy are you there?What are you doing?TimeHow is the patient?Was the patient discharged?
Subsequent Hospital Visits
99231Problem Focused IntervalHistory andProblem FocusedExaminationS or L Medical Decision Making99232Expanded Problem Focused IntervalHistory andExp Problem FocusedExaminationModerate Complexity Medical Decision Making99233Detailed IntervalHistory andDetailedExaminationHigh Complexity Medical Decision Making
Subsequent Hospital Visits
99231 –15 minutesUsually the patient isstable, recovering or improving99232 –25 minutesUsually the patient isresponding inadequately to therapyor has developed aminor complication.99233 –35 minutesUsually the patient isunstableor has developed asignificant complicationor asignificant new problem.
Subsequent Hospital Visits
Do not play it safe by just using 99231
Subsequent Hospital Visits
99231Medicare allows$32.5699232Medicare allows$53.1899233Medicare allows$75.61
Subsequent Hospital Visits
Example: 100 subsequent hospital visits80 99231 -$ 260510 99232 -$ 53210 99233 -$ 756 Total: $ 3893
Subsequent Hospital Visits
Example: 100 subsequent hospital visits60 99231 -$ 195430 99232 -$ 159510 99233 -$ 756Total: $4305
Evaluation and Management Services
Discharge ServicesTwo codes99238, 30 minutes or less99239, more than 30 minutesDocument time spentIt is appropriate to report hospital discharge on same day as nursing home admit
Critical Care
99291 , 99292
Critical Care
Do not code for less than 30 minutesUse the table in CPT for correct codingDoes not have to be continuous timeUnit/floor timeDoes not have to face to face time only99291 is only billed once per date of servicePatient status and care provided must both meet definition of critical
Consultations
Medicare Consultations
Effective January 1, 2010 Medicare willno longer coverconsultation CPT codes.99241 – 99245 Office/Outpatient99251 – 99255 Inpatient
Evaluation and Management Services- Consultations
For Medicare:New modifier to identify the actual admitting physician on record.AI(Two letters not alphanumeric)
Medicare Consultations - Inpatient
HX EX M (T)99251PF PF S 2099252EPF EPF S 4099253D D L 5599254C C M 8099255C C H 110
HX EX MDM (T)99221D D S/L 3099222C C M 5099223C C H 70
Medicare Consultations – Inpatient2013 Work RVU
992511.0992521.5992532.27992543.29992554.0
992211.92992222.61992233.86
Medicare Consultations - Inpatient
HX EX M (T)99251PF PF S 2099252EPF EPF S 40These two levels do not map to an initial inpatient visit code. The subsequent hospital visit CPT codes must be used.
HX EX M (T)99231PF PF S/L 1599232EPF EPF M 25
Medicare Consultations – Inpatient2013 Work RVU
992511.0992521.5
99231.76992321.39
Diagnosis Coding
Correct Diagnosis Coding
Basic Documentation Rules to Code by for Physician PracticesWhen coding from the medical record or source document only code those items clearly stated; DO NOT code anything listed as“possible”,“probable”,“maybe”,“suspected”
Correct Diagnosis Coding
Basic Documentation Rules to Code by for Physician PracticesThere are no “rule-out” codes
Correct Diagnosis Coding
Basic Documentation Rules to Code by for Physician PracticesBe as specific as possible; code acute conditions as “acute” and chronic conditions as “chronic”And be sure they are noted that way in the chart
Correct Diagnosis Coding
Basic Documentation Rules to Code by for Physician PracticesWhen a concisediagnosis cannot be made, code based onsigns and symptomsSigns and symptoms do not have to be separately listed if they are an integral part of the underlying diagnosis or condition already coded.