Expert answers can strengthen your documentation
Are you worried that your internist is downcoding subsequent-care claims, but you don't know what do? Use our experts'answers as a guide for documenting subsequent-care E/M components, body systems and service levels.
The bottom line: Underdocumenting can result in undercoding, which in a year could cost the physician thousands of dollars.
For example, suppose your internist believes his documentation won't support a higher-level subsequent-care code, so he always uses 99231. Because 99231 pays about $20 less than 99232, downcoding these claims just 10 times a month could cost your practice $2,400 per year, coding experts say.
Question 1: Did your internist specify two of the three E/M components?
To avoid underreporting and underpayment for subsequent-care claims, make sure your internist's documentation assigns two of the key components to the following daily subsequent-care codes for a patient's evaluation and management:
Remember: The key components are the history, the exam and the medical decision-making (MDM), says Brett Baker, third-party payment specialist for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) in Washington, D.C.
"The extent to which a physician performs history, exam, and medical decision-making determines the level of service that is selected for a subsequent hospital care visit," Baker says.
For instance, if the physician performs a subsequent-care visit on a diabetes (250.xx) patient and accurately documents an expanded problem-focused history and moderate-complexity medical decision-making, you may be able to report 99232. Helpful: You should consider medical decision-making the most important E/M component to satisfy because it best supports medical necessity, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.
Question 2: Did the internist report two to seven body systems?
If the internist sees a patient for congestive heart failure (428.0), the physician must examine and document at least two to seven body systems: constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (skin and/or breast); neurological; psychiatric; endocrine; hematologic/ lymphatic; and allergic/immunologic.
Question 3: How can I check whether we're accurately reporting 99231?
If your internal medicine practice repeatedly reports the same subsequent hospital care code, you should perform a chart review to ensure you're accurately coding the visits, coding experts say.
"Take a random sampling of charts where you reported 99231, and on each file you should determine the history, exam and medical decision-making levels and determine whether they meet the [...]