inpatient coding strategies
DESCRIPTION
Inpatient Coding Strategies. American College of Physicians March 1, 2013. Jaci Johnson CPC,CPMA,CEMC,CPC-H,CPC-I. President, Practice Integrity, LLC [email protected]. Disclaimer. - PowerPoint PPT PresentationTRANSCRIPT
Inpatient Coding Strategies
American College of PhysiciansMarch 1, 2013
DisclaimerInformation 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 Guidelines
GENERAL 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 by• type 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 Guidelines
1. The medical record should be complete and legible.2. The documentation of each patient encounter should
include:1. reason for the encounter and relevant history, physical examination2. findings and prior diagnostic test results;3. assessment, clinical impression or diagnosis;4. plan for care; and5. date and legible identity of the observer.
Evaluation and Management
READ THE GUIDELINES – Medicare Documentation Guidelines
3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
4. Past and present diagnoses should be accessible to the treating and/or consulting physician.
5. Appropriate health risk factors should be identified.
Evaluation and Management
READ THE GUIDELINES – Medicare Documentation Guidelines
6. 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 Guidelines
8. 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 Compliance Policy for Physician Practices
Medical 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 facility
NOT DOCUMENTED NOT DONE
Evaluation and Management Services
Hospital Services
Choosing 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 on level of service or
time• Do 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 Making
Subsequent Hospital Visits
• 99231, 99232, 99233• Every note stands alone• Why are you there?• What are you doing?• Time• How is the patient?• Was the patient discharged?
Subsequent Hospital Visits• 99231– Problem Focused Interval History and Problem Focused
Examination– S or L Medical Decision Making
• 99232– Expanded Problem Focused Interval History and Exp
Problem Focused Examination– Moderate Complexity Medical Decision Making
• 99233– Detailed Interval History and Detailed Examination– High Complexity Medical Decision Making
Subsequent Hospital Visits
• 99231 – 15 minutes– Usually the patient is stable, recovering or improving
• 99232 – 25 minutes– Usually the patient is responding inadequately to therapy
or has developed a minor complication.
• 99233 – 35 minutes– Usually the patient is unstable or has developed a
significant complication or a significant new problem.
Subsequent Hospital Visits
Do not play it safe by just using 99231
Subsequent Hospital Visits
99231Medicare allows $32.56
99232Medicare allows $53.18
99233Medicare allows $75.61
Subsequent Hospital Visits
Example: 100 subsequent hospital visits80 99231 - $ 2605
10 99232 - $ 532
10 99233 - $ 756Total: $ 3893
Subsequent Hospital Visits
Example: 100 subsequent hospital visits
60 99231 - $ 1954
30 99232 - $ 1595
10 99233 - $ 756Total: $4305
Evaluation and Management Services
Discharge Services• Two codes– 99238, 30 minutes or less– 99239, more than 30 minutes
• Document time spent• It 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 minutes• Use the table in CPT for correct coding• Does not have to be continuous time• Unit/floor time• Does not have to face to face time only• 99291 is only billed once per date of service• Patient status and care provided must both
meet definition of critical
Consultations
Medicare Consultations
Effective January 1, 2010 Medicare will no longer cover consultation 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)99251 PF PF S 20
99252 EPF EPF S 40
99253 D D L 55
99254 C C M 80
99255 C C H 110
HX EX MDM (T)
99221 D D S/L 30
99222 C C M 50
99223 C C H 70
Medicare Consultations – Inpatient2013 Work RVU
99251 1.0
99252 1.5
99253 2.27
99254 3.29
99255 4.0
99221 1.92
99222 2.61
99223 3.86
Medicare Consultations - Inpatient
HX EX M (T)99251 PF PF S 20
99252 EPF EPF S 40
These two levels do not map to an initial inpatient visit code. The subsequent hospital visit CPT codes must be used.
HX EX M (T)99231 PF PF S/L 15
99232 EPF EPF M 25
Medicare Consultations – Inpatient2013 Work RVU
99251 1.0
99252 1.599231 .76
99232 1.39
Diagnosis Coding
Correct Diagnosis Coding
Basic Documentation Rules to Code by for Physician Practices
When 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
Practices
There 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 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.