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Inpatient Coding Strategies. American College of Physicians March 1, 2013. Jaci Johnson CPC,CPMA,CEMC,CPC-H,CPC-I. President, Practice Integrity, LLC Disclaimer. - PowerPoint PPT Presentation


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Inpatient Coding StrategiesAmerican College of PhysiciansMarch 1, 2013Jaci JohnsonCPC,CPMA,CEMC,CPC-H,CPC-IPresident, Practice Integrity, LLCjaci@practiceintegrity.comDisclaimerInformation 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 ManagementREAD 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 ManagementREAD 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 ManagementREAD 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 ManagementREAD 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 ManagementREAD 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 ManagementREAD THE GUIDELINES OIG Compliance Policy 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 DoneCoding 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 ServicesHospital Services

Choosing the correct level of service is important in hospital setting also. Hospital ChargesHow 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 ServicesHospital admission (99221 99223)Code selection based on level of service or timeDo not bill for other related E&M services on same date of admission Describes the first inpatient encounter with the patient.Evaluation and Management Services99221 (30 minutes)Detailed or comprehensive history and exam Straightforward 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 MakingSubsequent Hospital Visits99231, 99232, 99233Every note stands aloneWhy are you there?What are you doing?TimeHow is the patient?Was the patient discharged?

Subsequent Hospital Visits99231Problem Focused Interval History and Problem Focused ExaminationS or L Medical Decision Making99232Expanded Problem Focused Interval History and Exp Problem Focused ExaminationModerate Complexity Medical Decision Making99233Detailed Interval History and Detailed ExaminationHigh Complexity Medical Decision Making

Subsequent Hospital Visits99231 15 minutesUsually the patient is stable, recovering or improving

99232 25 minutesUsually the patient is responding inadequately to therapy or has developed a minor complication.

99233 35 minutesUsually the patient is unstable or has developed a significant complication or a significant new problem.Subsequent Hospital VisitsDo not play it safe by just using 99231

Subsequent Hospital Visits99231Medicare allows $32.56

99232Medicare allows $53.18

99233Medicare allows $75.6119Put up grid on overheadSubsequent Hospital VisitsExample: 100 subsequent hospital visits80 99231 - $ 2605

10 99232 - $ 532

10 99233 - $ 756Total: $ 3893

20Assume 20% should be coded a level 2Subsequent Hospital VisitsExample: 100 subsequent hospital visits

60 99231 - $ 1954

30 99232 - $ 1595

10 99233 - $ 756Total: $430521This shows an increase of $8,300. This is only 100 patients.Evaluation and Management ServicesDischarge ServicesTwo codes99238, 30 minutes or less99239, more than 30 minutesDocument time spentIt is appropriate to report hospital discharge on same day as nursing home admitCritical Care99291 , 99292Critical CareDo 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

ConsultationsMedicare ConsultationsEffective January 1, 2010 Medicare will no longer cover consultation CPT codes. 99241 99245 Office/Outpatient99251 99255 InpatientEvaluation and Management Services- ConsultationsFor Medicare:

New modifier to identify the actual admitting physician on record.AI(Two letters not alphanumeric)

Medicare Consultations - InpatientHXEXM (T)99251PFPFS 20

99252EPFEPFS 40

99253DDL 55

99254CCM 80

99255CCH 110HXEXMDM (T)99221DDS/L 30

99222CCM 50

99223CCH 70Medicare Consultations Inpatient2013 Work RVU992511.0





992233.86Medicare Consultations - InpatientHXEXM (T)99251PFPFS 20

99252EPFEPFS 40

These two levels do not map to an initial inpatient visit code. The subsequent hospital visit CPT codes must be used.HXEXM (T)99231PFPFS/L 15

99232EPFEPFM 25

Medicare Consultations Inpatient2013 Work RVU992511.0




Diagnosis CodingCorrect Diagnosis CodingBasic 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 aspossible, probable, maybe, suspected

Correct Diagnosis CodingBasic Documentation Rules to Code by for Physician Practices

There are no rule-out codesCorrect Diagnosis CodingBasic Documentation Rules to Code by for Physician PracticesBe as specific as possible; code acute conditions as acute and chronic conditions as chronicAnd be sure they are noted that way in the chart

Correct Diagnosis CodingBasic Documentation Rules to Code by for Physician PracticesWhen a concise diagnosis cannot be made, code based on signs and symptoms Signs and symptoms do not have to be separately listed if they are an integral part of the underlying diagnosis or condition already coded.


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