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CPT Coding, Cash, and Compliance

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Presentation on theme: "CPT Coding, Cash, and Compliance"— Presentation transcript:

1 CPT Coding, Cash, and Compliance
12/4/2014 CPT Coding, Cash, and Compliance Inpatient Coding Thomas Weida, M.D. Professor Department of Family and Community Medicine Penn State Milton S. Hershey Medical Center © 2014, Thomas J. Weida, M.D.

2 Disclosures I have nothing up my sleeve.
12/4/2014 Disclosures I have nothing up my sleeve. I have nothing to disclose other than I’m on everyone’s best loved committee – the RUC © 2014, Thomas J. Weida, M.D.

3 Comorbidities are important
12/4/2014 Outpatient tends to under-code Inpatient tends to over-code Comorbidities are important © 2014, Thomas J. Weida, M.D.

4 Initial Hospital Care – New or Established: 3 Key Components
Capture the Coding, Inpatient Initial Hospital Care – New or Established: 3 Key Components 99221: Ave 30 min bedside or floor Decision making – low complexity Detailed history, detailed physical 99222: Ave 50 min bedside or floor Decision making moderate complexity Comprehensive history, comprehensive physical 99223: Ave 70 min bedside or floor Decision making of high complexity The rest of this presentation involves proper coding for inpatient visits. In my experience, physicians typically over-code hospital visits when the patient is improving, and under-code when patients have complicating factors. For admission history and physicals, the codes are the same for established or new patients. There are three levels based on decision making of low, moderate and high complexity. A has decision making of low complexity and a detailed history and physical. Typically, the physician spends 30 minutes at the bedside or floor for this admission. A involves medical decision making of moderate complexity and a comprehensive history and physical. Typically 50 minutes is spent at bedside or floor. Finally, a has medical decision making of high complexity and a comprehensive history and physical. Time is typically 70 minutes. So for admissions, there’s small, medium and large. Also, when documenting a note for inpatient care, remember to document all pertinent diagnosis's. Also, the documentation needs to be diagnosis's and not symptoms. For example, writing a down arrow and a K will not add to the complexity. This is not considered a diagnosis. Writing hypokalemia is a diagnosis, and will add to the complexity. 12/4/2014 © 2014, Thomas J. Weida, M.D. Thomas J. Weida, M.D. PennState College of Medicine

5 Subsequent Hospital Care
Capture the Coding, Inpatient Subsequent Hospital Care 99231: Patient is stable, recovering or improving. Average of 15 minutes. 2 of 3 Key Components Decision making: Low Complexity Problem focused interval history Problem focused physical Subsequent hospital care also has 3 levels. For the patient is stable, recovering or improving. Decision making is of low complexity. The history is a problem focused interval history and the physical is a problem focused physical. You only need 2 of these three components to qualify: medical decision making, history, and physical. Typically 15 minutes is spent at bedside and on the patient’s hospital floor or unit. 12/4/2014 © 2014, Thomas J. Weida, M.D. Thomas J. Weida, M.D. PennState College of Medicine

6 Subsequent Hospital Care
Capture the Coding, Inpatient Subsequent Hospital Care 99232 – Patient is not responding to treatment or has developed a minor complication. Average of 25 minutes. 2 of 3 Key Components Decision making: Moderate Complexity Expanded problem focused interval history Expanded problem focused physical For a 99232, the patient is responding inadequately to therapy or has developed a minor complication. Two of the three following key components must be met: medical decision making of moderate complexity, an expanded problem focused interval history, and an expanded problem focused interval physical. Average time spent at bedside, on unit or floor is 25 minutes. And remember, just like in the history and physical, complications must be diagnosis’s, not symptoms, and it must be in your note. Just because the Chest X-ray says right lower lobe air space disease, it won’t be considered a diagnosis until you record pneumonia in your note. 12/4/2014 © 2014, Thomas J. Weida, M.D. Thomas J. Weida, M.D. PennState College of Medicine

7 Subsequent Hospital Care
Capture the Coding, Inpatient Subsequent Hospital Care 99233 – Patient is unstable or has developed a significant complication or a significant new problem. Average of 35 minutes. 2 of 3 Key Components Decision making: High Complexity Detailed interval history Detailed physical The highest level is The patient is unstable or has developed a significant complication or a significant new problem. Two of the three following key components must be met: medical decision making of high complexity, a detailed interval history, and a detailed interval physical. Average time spent at bedside, on unit or floor is 35 minutes. So briefly, the patient is stable, 99232, the patient is a little worse or not improving, and the patient is a lot worse or has a new problem. 12/4/2014 © 2014, Thomas J. Weida, M.D. Thomas J. Weida, M.D. PennState College of Medicine

8 Initial Observation Care: New or Established, 3/3 Key Components
99218 Low Complexity Decision Making Detailed History, Detailed Exam 99219 Moderate Complexity Decision Making Comprehensive History, Comprehensive Exam 99220 High Complexity Decision Making 12/4/2014 © 2014, Thomas J. Weida, M.D.

9 Observation or Inpatient Admission & Discharge Same Day 3/3 Key Components
Must be more than 8 hours and less than 24 hours 99234 Low Complexity Decision Making Detailed History, Detailed Exam 99235 Moderate Complexity Decision Making Comprehensive History, Comprehensive Exam 99236 High Complexity Decision Making 12/4/2014 © 2014, Thomas J. Weida, M.D.

10 Subsequent Observation Care 2/3 Key Components
99224 – Stable, Recovering, Improving 15 min Low Complexity Decision Making Problem focused interval history Problem focused exam 99225 – Not responding or new minor problem 25 min Moderate Complexity Decision Making Expanded problem focused interval history Expanded problem focused exam 99226 – Unstable or significant new problem 35 min High Complexity Decision Making Detailed interval history Detailed exam 12/4/2014 © 2014, Thomas J. Weida, M.D.

11 Prolonged Physician Service with Direct Patient Contact, Inpatient
Does not have to be continuous time CPT: face-to-face and on unit Medicare: face-to-face Use with E&M code which has average time listed < 30 min: NO Code 30-74 min: X 1 min: X 1 and 99357 >105 min: X 1 and X 2 or more for each additional 30 min (must be greater than 15 min additional for each use of 99357) Document time 12/4/2014 © 2014, Thomas J. Weida, M.D.

12 http://thehappyhospitalist. blogspot
12/4/2014 © 2014, Thomas J. Weida, M.D.

13 99356 Example 34- year old primigravida presents to hospital in early labor. Patient has severe preeclampsia. Physician supervises management of preeclampsia, IV magnesium, labor augmentation with pitocin and close maternal-fetal monitoring. Physician face-to-face involvement includes 40 minutes of continuous bedside care until the patient is stable, then is intermittent over several hours until the delivery. 12/4/2014 © 2014, Thomas J. Weida, M.D.

14 Observation Care Discharge Services: 99217
Discharge on separate day than admission from observation status Cannot use and for service on the same day. 12/4/2014 © 2014, Thomas J. Weida, M.D.

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