Are you confused about how to code for subsequent hospital care? If so, you are not alone.
The Centers for Medicare & Medicaid Services has identified a nationwide trend of physicians billing Medicare for levels of subsequent hospital care (CPT codes 99231-99233) that their patient's condition does not support.
The problem in these cases is that the extent of the history documented, the extent of the physical examination documented, and the level of medical decision-making are greater than what the patient's condition requires.
Remember, you must bill Medicare only for activities that are reasonable and necessary for the diagnosis or treatment of illness or injury. Codes 99231-99233 require documentation of the:
- Interval history as either problem-focused, expanded problem-focused, or detailed;
- Examination as either problem-focused, expanded problem-focused, or detailed; and
- Medical decision-making as straightforward or of low, moderate, or high complexity.
The nature of the presenting problem usually determines the levels of history and physical exam required.
- CPT code 99231 usually requires documentation to support that the patient is stable, recovering, or improving.
- CPT code 99232 usually requires documentation to support that the patient is responding inadequately to therapy or has developed a minor complication. Such minor complication might call for careful monitoring of comorbid conditions requiring continuous, active management.
- CPT code 99233 usually requires documentation to support that the patient is unstable or has a significant new problem or complication.
It is reasonable to expect higher levels of history and physical exam to be needed in the days immediately following a hospital admission. These higher levels most likely would not be medically necessary when the patient is stable and improving, particularly in the visits on days preceding discharge from the hospital.
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