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Hospitalist Coding and Billing (For Dummies)
Judith Hooffstetter, MD Hospitalist
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Objectives Describe basics of coding and billing
List documentation requirements for E/M levels Explain new consultative codes
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Anatomy of a Charge Card
H&P OBS Subsequent F/U Admitting 99221 99218 99231 AI 99222 99219 99232 99223 99220 99233 DX ICD-9 Code Acute on Chronic CHF 428.23 A fib 427.31 DMII Uncontrolled 250.0 Hypothyroid Stable 246.9 COPD 496.0
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ICD-9 and CPT Relationship
CPT codes explain WHAT service was performed (level of visit or procedure) ICD codes explain WHY the service was performed (the diagnosis)
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ICD-9 Classification based system that groups data into broad categories Required by the World Health Organization for reporting mortality data for comparison across countries. ICD-9 CM is a modification of the code and has been used in the US since 1979.
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Anatomy of ICD-9 CM Have 3,4 or 5 numeric or alpha numeric codes
17 main division of chapters and then further broken down into code sections, code categories, code subcategories and code subclassifications. The more numbers, the more specific
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Ventricular fibrillation and flutter
427 427.4 427.41 Cardiac dysrhythmia Ventricular fibrillation and flutter Ventricular fibrillation only
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Current Procedural Terminology (CPT)
CPT (Current Procedural Terminology) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services. They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer.
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CPT Codes for Hospitalists
Admit and Consult Codes Subsequent Follow Up Critical Care Codes Extended Time Codes Discharge Codes
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How You Get Paid!!
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Admission Codes for Hospitalists CMS
99221 – 99223 + AI (admission modifier)
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Elements for E&M visits (How you document for the level)
History – CC – HPI– ROS – PFSH (past, family, social history)• Exam – number of organ systems Decision making – #diagnoses or management options – Amount of data/complexity – risk level to patient
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Inpatient Level of Care
Key Components 99221 99222 99223 Patient History Detailed Comprehensive Patient Exam Medical Decision Making (MDM) Low Moderate High For H&P 3 of 3 key elements need to be met
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Subsequent Level of Care
Key Components 99231 99232 99233 Patient History Problem focused Expanded Problem Focused Detailed Interval Patient Exam Detailed MDM Straightforward Moderate High Subsequent Care requires 2/3 elements
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History Matrix Type of History HPI ROS FH/SOC Hx Problem focused
Brief (1-3 elements) n/a Exp Problem Focused Brief (1-3) Problem Pert. (1 system) Detailed Extended (4 elements or status of 3 chr Extended (2-9 systems) Pertinent (1 element) Comprehensive Extended Comprehensive (10 system) Complete 3/3
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ROS Must Note Pertinent Positives and Negatives in at least 10 systems for Comprehensive Can no longer say all ROS negative (Can refer to check list on written guide) Can say unable to obtain from patient (if patient obtunded etc).
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Organ Systems (1997 Guidelines)
Cardiovascular Respiratory Ear, Nose, and Throat Eye Genitourinary Hematologic/Lymphati c/Immunologic Musculoskeletal Neurological Psychiatric Skin
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Patient Exam Type of Exam Required PE Problem Focused
1 – 5 bullets (or one body system or organ system) Expanded Problem Focused 6 bullets (2-4 body areas or organ systems) Detailed At least 2 bullets from specified systems or 12 bullets (5-7 body areas or organ systems) Comprehensive 18 elements with at least 2 from each system (8+ body areas or organ system)
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Medical Decision Making Matrix
Type of Decision Making Number of Diagnosis Amount and complexity of data Risk of Complication or Morbidity or Mortality Straightforward Minimal (≤1) Minimal (1) or none Minimal Low Limited (2) Moderate Multiple (3) Moderate (3) High Extensive (≥4) Extensive ≥4 MUST MEET 2/3 COMPONENTS Final MDM requires that 2 of 3 above components are met or exceeded
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Amount and complexity of data
Action Points Review And/or order clinical test (labs) 1 point Review and/or order of radiology Review and/or order of medical test (vaccines, echo, ekg, pft) Discussion of test with performing MD Independent review of test 2 points • Old records or hx from another person and summarizing
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Moderate Complexity One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, eg, lump in breast Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis Acute complicated injury, eg, head injury with brief loss of consciousness Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test Diagnostic endoscopies with no identified risk factors
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High Complexity One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment Acute or chronic illnesses or injuries that pose a threat to life or bodily function, An abrupt change in neurologic status, eg, seizure, TIA, weakness, sensory loss Cardiovascular imaging studies with contrast with identified risk factors Elective and emergency major surgery Parenteral controlled substances or drug therapy requiring intensive monitoring for toxicity
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Pearls Action Level Prescription drug management moderate
2+ stable chronic illness Abrupt MS change (seizure, TIA) high 1 chronic illness w/severe exacerbation, progression Make DNR Cardiovascular imaging studies with contrast with identified risk factors Emergent major surgery Parenteral pain medication
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Subsequent Level of Care
Key Components 99231 99232 99233 Patient History Problem focused Expanded Problem Focused Detailed Interval Patient Exam Expanded Problem Focused (6) Detailed (12) MDM Straightforward Moderate High Subsequent Care requires 2/3 elements
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Time Based Coding for Subsequent Care
When counseling/coordination of care is > 50% of service AND When TIME based code would be higher level of service
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Time Based Code CPT CODE Time 99231 15 minutes 99232 25 minutes 99233
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Inpatient Consults Request for consult must be documented by requesting and completing physician Consulting physician must document opinion and/or advice (send cc to requesting physician) Document the problem for which YOU are seeing the patient (to prevent concurrent care denials) Document time = total time
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Consults Codes (CMS)
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Consult Codes No longer use consult codes (99251-99255) for CMS
Can still use them for commercial payers Use admission codes (but without the AI modifier). Can use prolonged service codes ( ) if applicable
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Crosswalk for Inpatient Consults
Old CPT History Exam MDM New code 99253 Det Hx Det Exam At least 2 bullets from specified systems or 12 bullets Low 99221 99254 Comp Hx 18 elements with at least 2 from each system Moderate 99222 99255 High 99223
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Prolonged Service Codes 99356-99357
Greatly increases reimbursement Use with and when appropriate Never use with 99231 CAN BE A FLAG FOR MEDICARE AUDITS – so must be used appropriately and well documented
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Discharge Codes 99238 Used when time is less <30 minutes 99239
MUST DOCUMENT IN YOUR DICTATION TIME SPENT
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TO RECAP
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Inpatient Admission Level 3
Component Level 3 Requirements History Comprehensive Exam 18 elements with at least 2 from each system MDM High
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Subsequent Visit Level 2
Component Service Required Exam Problem focused - 6 bullets MDM Moderate OR DOCUMENT BASED ON TIME
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Subsequent Visit Level 3
Component Required Exam 18 elements with at least 2 from each system MDM High OR BASED ON TIME
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