Policy: Effective January 1, 2010, Procedure consultation codes were no longer recognized for Medicare Part B payment. As explained in CR 6740, Transmittal 1875, Revisions to Consultation Services Payment Policy, issued on December 14, 2009, physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. CMS instructed providers billing under the PFS to use other applicable E/M codes to report the services that could be described by Procedure consultation codes. CMS also provided that, in the inpatient hospital setting, physicians (and qualified nonphysicians where permitted) who perform an initial E/M service may bill the initial hospital care codes (99221 – 99223).
CMS is aware of concerns pertaining to reporting initial hospital care codes for services that previously could have been reported with Procedure consultation codes and for which the minimum key component work and/or medical necessity requirements for Procedure codes 99221 through 99223 are not documented. Providers may report Procedure code 99221 for an E/M service if the requirements for billing that code, which are greater than Procedure consultation codes 99251 and 99252, are met by the service furnished to the patient.
In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care Procedure codes (99231 and 99232) could potentially meet requirements to be reported for an E/M service that could be described by Procedure consultation code 99251 or 99252. Contractors shall expect changes to physician billing practices accordingly. Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay
The general policy of billing the most appropriate visit code, following the elimination of payments for consultation codes, shall also apply to billing initial visits provided in skilled nursing facilities (SNFs) and nursing facilities (NFs) by physicians and nonphysician practitioners (NPPs) who are not providing the federally mandated initial visit. If a physician or NPP is furnishing that practitioner’s first E/M service for a Medicare beneficiary in a SNF or NF during the patient’s facility stay, even if that service is provided prior to the federally mandated visit, the practitioner may bill the most appropriate E/M code that reflects the services the practitioner furnished, whether that code be an initial nursing facility care code (Procedure codes 99304-99306) or a subsequent nursing facility care code (Procedure codes 99307-99310) when documentation and medical necessity do not meet the requirements for billing an initial nursing facility care code.
In the CY 2011 PFS final rule with comment period (CMS-1503-FC), CMS recognized the newly created Procedure subsequent observation care codes (99224-99226). For the new subsequent observation care codes, the current policy for initial observation care also applies to subsequent observation care. Payment for a subsequent observation care code is for all the care rendered by the ordering physician on the day(s) other than the initial or discharge date. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.
In the rare circumstance when a patient receives observation services for more than 2 calendar dates, the physician shall bill observation services furnished on day(s) other than the initial or discharge date using subsequent observation care codes.
Sometimes we have patients who just don’t meet 99233 criteria for additional days in the hospital. I often find myself asking “Why not discharge them?” Inevitably it is for silly things like
1. Needs IV abx
2. Awaiting placement
3. Has a ride tomorrow
4. Getting therapeutic (Although if there is a PE involved, you go to the 99233 line)
In these cases I find it necessary to review why we missed the 99233 and why I need to code as a 99232…..
For your edification…….
a 99232 is a subsequent day of care in the hospital Which needs you to meet 2 of 3 criteria.
The best part about this coding system is that when you have already established care with the patient, the criteria for upper level codes is far less….
In this case the 2 of 3 are
1. Expanded Problem Focused interval history
2. An expanded Problem Focused examination
3. MDM of moderate complexity
So again with the sub-categorization of what expanded problem focused means….
Exanded Problem Focused History is:
A chief complaint, a brief HPI (containing one to three HPI ), plus one ROS. No PFSH is required.
Are you telling me you only do ONE ROS? And only one HPI element? If you do 3, you better do 4 elements. If you do one ROS, you really should do more……..Why? It serves the patient better to look for things and think about the case. Too much of medicine is driven to mindless care……
Expanded Problem Focused Exam is:
6 bullet points from one or more system.
Heart and Lungs? Yup…..all done…..
Basically this is a gimme. Did you end up doing more than this? Then you should consider the 99233
Lastly you need to factor in Medical Decision Making…..and in this case it is of moderate complexity…..
What is Moderate Complexity? Remember, this category is judged by
1. Problem Points- I.E. what is the nature of the problem.
2. Data Points- I.E. what work did you review and cogitate over
3. Risk Level- I.E. risk to patient’s life
Again, you only need 2 of 3 at the highest level
The risk is evaluated in a risk table presented best at EM University.
One chronic problem with mild exacerbation gives you moderate risk so do 2 stable controlled diseases i.e. hypertension and hyperlipidemia
So you can usually get 2 of 3 here pretty easily. But you should always ask yourself…….did I really do a 99233 instead of a 99232…..It is just good medicine.
