I’ve been around long enough in a society so chock full of people equally split between those with neuroses and those in denial to learn that there are varying definitions to the term “seriously ill”, depending on who you happen to encounter in a given day. My Aunt Edith, a lovable lady to her core, so enjoyed talking about her various maladies that she could describe her latest paper cut in terms usually reserved for near-amputations. Yet in the end, a band-aid and a few days was usually the best treatment option.

Having audited inpatient documentation, I can draw a parallel between poor Aunt Edith’s fingers and a physician selecting a level of service for a subsequent hospital visit. The preponderance of evidence suggests that in both cases, there’s quite a bit of self-defeating exaggeration to be found.

When someone asks me what I believe to be the most over-reported E/M service, it takes me very little time to say “99233″. I can count on one hand the number of times where I have seen this code reported where the documentation actually justified the billing of a level 3 subsequent hospital visit.

The Medicare Comprehensive Error Rate Testing (CERT) reports bear this belief out to some extent. CPT code 99223 (level 3 initial encounter) was shown to be overpaid 21.5 percent of the time, but coming in a close second was 99233, with an error rate of over 18 percent. I have seen poor documentation for both of these codes numerous times, and I can tell you that 99223, from a documentation perspective, can be fixed with provider education in a fairly short time frame. For 99233, the documentation in most cases doesn’t even come close to substantiating the reporting of the code. The nature of subsequent hospital visits being handwritten makes correcting the problem a laborious task from start to finish.

When the topic of subsequent hospital visits comes up, from an educational standpoint, I like to go back to the very beginning, which is the CPT definition for each of the three codes. In the CPT, at the bottom of each code description, is a small paragraph which gives an overview of a typical patient’s condition for the code. As the level of service goes higher, there is an acuity level that must be met to satisfy the usage of the code. To start, 99231 states “Usually, the patient is stable, recovering or improving”. Moving forward, 99232 states “usually, the patient is responding inadequately to therapy or has developed a minor complication”. Finally, 99233 states “usually, the patient is unstable or has developed a significant complication or a significant new problem”.

If you are currently a provider billing a large volume of 99233’s, take a good look at these descriptions. In a philosophical sense, I am in agreement with the idea that a hospital stay is usually reserved for those whose illness has exceeded the person’s capacity for self-care. Yet it should not be a common occurrence for a patient whose illness has been identified upon admission and whose course of treatment has been defined to be unstable throughout a large portion of their hospital stay. Utilizing the definitions above, 99231 and 99232 would describe the large percentage of subsequent hospital visits. To put it in the context of a recent example, Aunt Edith seems like a 99233, but is more than likely a 99231.

Additionally, if you’re billing a 99233 a day prior to discharge, I would hope that your discharge documentation includes the words “magic wand”, as you are reporting that the patient is unstable and/or has a complication of care. A discharge the following day would be unlikely.

Based on the direction that CMS has been taking with hospital-acquired conditions (HAC’s), I can see a day when 99233’s are only paid within 1 to 3 days of admission. Currently, taking HAC’s into account is in a reporting-only stage, but I believe we are headed towards a time when hospitals will face little (or perhaps, no) reimbursement for the treatment of HAC’s. This is a fact that, unfortunately, cannot be remedied by improved documentation on the part of the managing physician.  

We now have three of the four recovery audit contractors looking at certain hospital DRG’s for medical necessity, with the current list expected to expand over time. As RAC’s begin to widen their efforts into the physician arena, it would make sense for 99233’s to be on their immediate radar. This is particularly true if they have determined that a hospital stay did not fall under the parameters of medical necessity based on a complex review of the hospital records for an inpatient stay.

For the tens of thousands of physicians who happen to come across this particular posting and say, “…but I spend a lot of time with my patients, and….”, I offer this. While there are average times for each of the three codes for subsequent hospital visits (to save you time, 15 minutes for 99231, 25 minutes for 99232 and 35 minutes for 99233), it is important to remember a few points. First, the documentation must state “I spent XX minutes with this patient, more than 50% of which was spent counseling and/or coordinating care”. Second, there must be documentation of what topics were covered during the counseling (weather and other local and national news updates do not count for purposes of coding), or what specific steps were taken to coordinate the care for the patient. Simply writing something like “spent time counseling” is insufficient.

Finally, know that RAC’s are enforcing CMS’ recently implemented and heightened signature requirements when auditing your documentation. If it does not include a recognizable signature, your service is not authenticated and did not happen from the RAC’s point of view.

To complete our cycle, next week’s edition of The RAConteur will take a look at the reporting and documentation of  initial inpatient encounters (CPT codes 99221 thru 99223).

10:11 am, September 15th, 2010 |