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How hospitalists can avoid common errors when billing for subsequent hospital care

Hospitalist Management Advisor, July 1, 2006

As the physician who is always in, the hospitalist frequently bills Medicare and other payers for providing subsequent hospital care to patients during their hospital stays. Incidentally, subsequent hospital care tops the list of coding problems that the Centers for Medicare & Medicaid Services (CMS) identifies in its Comprehensive Error Rate Testing program and Hospital Payment Monitoring Program, both established by CMS to monitor the accuracy of payments made on behalf of Medicare patients.

Scope of the problem

All three levels of subsequent hospital care, from least to most complex (codes 99231 to 99233), appear on CMS’ top-20 list of services receiving improper payments due to insufficient documentation, according to CMS’ May 2006 report Improper Medicare Fee-for-Service Payments, which is based on reviews of thousands of Medicare claims.

Editor’s note: Insufficient documentation” means that the provider excluded essential facts about the patient (e.g., overall condition, diagnosis, extent of services performed, etc.) in the medical record documentation submitted.

The payment error rate was 7.8% for 99232 (moderate complexity) for projected improper payments of $175 million in 2006, 7.3% for 99233 (high complexity) for projected improper payments of $86 million in 2006, and 6.7% for 99231 (low complexity) for projected improper payments of $32 million for the period from July 2004 to June 2005.

Common coding errors

One common mistake that hospitalists make when documenting subsequent hospital care is failing to document the patient’s current status, says Charleen Porter, BA, MA, CPC, healthcare consultant and billing and coding consultant for VEI/IMM, a practice management firm affiliated with the Community Health Network in Indianapolis.

Hospitalists must indicate the severity of the patient’s problems at that visit, she says. “You have to tell me your thinking process for why the patient needs this high level of care. I’ve seen physician notes that say ‘patient looks better today,’ ” Porter adds. “Then why are they still at a level 3 service?”

Porter says physicians are under time constraints and often keep documentation to a minimum, which can contribute to billing errors. However, she advises hospitalists to document more method-ically—similar to residents who are new to the process. For example, it might seem redundant to hospitalists to include test results in their documentation, but Porter adds that auditors might not receive test results as part of the documentation on the claim. Also, many first-line auditors don’t have a clinical background.

Porter says the days when physicians could write “the patient looks good,” perform a minimal exam, leave orders to “continue present management,” and then charge for a level 3 service are gone. “If you’re going to keep the reimbursement, you need to put a little more on paper,” she says. Adding information about comorbidities to the record may allow the hospital to bill for a higher level of service, Porter notes.

“Tapering down” of patient care

Lynn Hickman, MD, Louisiana and New Mexico medical director for Oklahoma City–based Pinnacle Business Solutions, Inc., a Medicare carrier and intermediary, says patients typically should not receive level 3 service for their entire hospital stay.

In the first days of a patient’s hospitalization, you might expect to see coding for level 3 subsequent hospital care, but generally there should be a “tapering down” of the level of service, particularly just prior to discharge, Hickman says.

“If you are coding correctly, there should be continuing improvement with less visit time and less work involved in management,” says Hickman.

“It is reasonable to expect higher levels of history and physical [H&P] exam to be needed in the days immediately following a hospital admission; following transfer from intensive care; or following an acute exacerbation, complication, or decompensation of the patient’s condition(s),” wrote Hickman in the May 2004 Medicare Providers’ News.

“It is not expected that these higher levels would be medically necessary when the patient is stable and improving, particularly in the visits on days preceding discharge from the hospital. Documentation of H&P examinations and medical decision-making should not be performed or billed at levels greater than needed for the patient’s condition,” Hickman says.

Porter adds that some specialists say they should only see patients requiring level 5 outpatient visits. Likewise, some hospitalists feel that they should only be working at level 3. Porter responds to such assertions by saying, “Not everybody that you visit is on the verge of demise or organ failure.”

CMS has identified the practice of billing subsequent hospital care that’s unsupported by the patient’s condition as a nationwide problem. In a review of claims for oncology patients in Oklahoma from May to September 2005, for example, reviewers found that the extent of documented H&P exams was greater than the levels required by the patients’ conditions. Subsequently, 78 of 237 services were recoded to 99231.

Using templates and training to code better

At the University of Pennsylvania Health System, Mary Mulholland, RN, CPC, MHA, from the Office of Clinical Documentation for the Department of Medicine, says her hospital has developed templates to guide physicians in providing accurate documentation. Providers can choose to use either Medicare’s 1995 or 1997 guidelines for documentation of patient examination. She prefers the 1995 examination guidelines, calling them “less onerous.” The 1995 examination guidelines provide the physician with the flexibility to document the examination points most specific to the needs of their patients, she says.

“If you are an auditor or abstractor, you use lists and reminders for documentation when coding physician services. Physicians generally don’t have lists, and they are often interrupted when documenting their services,” she says. A template assists providers in documenting the key components of the evaluation and management service. The template also reminds them about basic steps (e.g., documenting the date and duration of service, signing their clinical notes, etc.). Mulholland says use of templates helps save valuable provider time, improves the detail included in the documentation of the encounter, and improves efficiency.

Mulholland and Hickman stress the importance of taking advantage of the coding training provided by professional societies and Medicare carriers. To avoid being an outlier on billing for level 3 subsequent hospital care—thereby increasing your chances for an audit—Porter recommends that you obtain a comparative billing report from your local Medicare carrier. These reports enable physicians to compare billings on a specific code or code ranges to peers in the same state with the same or similar specialty types. To be paid correctly, physicians must provide more detail in chronicling patients’ problems and their severity, and must also better document their medical decision-making and the appropriate level of assessment, says Porter. A complete record not only helps ensure reimbursement, but also benefits patients and colleagues, she adds.

Porter’s outlook lends credence to the fact that hospitalists should take the time to become well versed in proper coding and billing procedures. “I don’t see anybody cutting anyone any slack. [Payers are saying], ‘We want to know what we’re paying for, and the only way we’re going to know is if you’re telling us. We’re not going to make any assumptions.’ ”

Editor’s note: See p. 9 of the PDF of this issue for a chart containing examples of low-, moderate-, and high-risk examples of patients’ presenting problems, as well as relevant diagnostic test orders and management options (from Tools and Strategies for an EffectiveHospitalist Program, HCPro, Inc., 2006).

Ensure coding at the correct level for subsequent hospital visit

Subsequent hospital visits require two of three key components of the history and physical, patient examination, and medical decision-making process. Current communication from the Centers for Medicare and Medicaid Services (CMS) indicates that when a level 3 subsequent visit is chosen, the practitioner must demonstrate high-complexity medical decision-making.

The Current Procedural Technology book published by the American Medical Association describes the level 2 subsequent hospital visit (99232) as typically consisting of “25 minutes at the bedside and on the patient’s floor or unit.” The level 3 subsequent hospital visit (99233) typically consists of “35 minutes at the bedside and on the patient’s hospital floor or unit.” If more than 50% of the time spent face-to-face with the patient is consumed by counseling the patient or family regarding the patient’s management, prognosis, etc., or in coordination of care, the service can be billed using time as the key component.

The total visit time and the time spent in counseling or coordination of care activities should be documented in the record (e.g., total visit time was 35 minutes; time spent counseling regarding xyz was 15 minutes).

Source: Tools and Strategies for an Effective Hospitalist Program, published by HCPro; Chapter 11: “Coding and compliance for the inpatient physician.” For more information, visit www.hcmarketplace.com/prod-4013.html.

Codes describing subsequent hospital care

Codes 99231–99233 describe subsequent hospital care and require documentation of the interval history at either the problem-focused, expanded problem-focused, or detailed level.

The examination requires the same levels of documentation. The documentation must support straightforward low-, moderate-, or high-complexity medical decision-making. The nature of the patient’s presenting problem usually determines the level of history and physical exam required.

1. Current procedural technology (CPT code) 99231 usually requires documentation to support that the patient is stable, recovering, or improving.

2. CPT code 99232 usually requires documentation to support that the patient is responding inadequately to therapy or has developed a minor complication. Such minor complications might include careful monitoring of comorbid conditions requiring continuous active management.

3. CPT code 99233 usually requires documentation to support that the patient is unstable or has a significant new problem or complication.

Source: “Coding of Subsequent Hospital Care,” by Lynn E. Hickman, MD; Medicare Providers’ News, May 2004 (www.oknmmedicare.com/provider/provnewslet/pdfformat/mcb200405.pdf).