Hospital Services – A different mindset for documentation

As we have moved into a new era of CMS compliance measures, the importance of solid hospital coding and documentation is a must to avoid unnecessary audits. With the onslaught of RAC’s aggressively beginning to focus on hospital services around the country, training internal coding staff and physicians will be the key to survival. Criteria for hospital admission services (99221-99223) are frequently under documented by physicians. Further, the use of time (counseling & coordination of care) is often overlooked as a means for meeting both admission and subsequent criteria. 

Using 1995 CMS documentation criteria, the lowest admission code, 99221 requires a detailed history, detailed exam with straightforward/low decision making. Along with an extended (4+) HPI and a pertinent (1 area) of past, family and/or social history, review of systems tends to be where documentation lacks most often. A detailed ROS translates into at least a 2-9 system review. If the patient is unable to relay such information (unconscious, sedation, etc.), it is imperative that the physician documents this condition and that an attempt was made to obtain information. This would allow some flexibility in coding a system review as an effort was made to collect the data.

Time is another means for coding an admission if the counseling/coordination of care criteria is met. Most importantly, time must be documented in the permanent medical record. A superbill or hospital charge form is typically not a permanent part of the inpatient medical record. Additionally, there must be some justification that over 50% of the time spent with was patient was performing counseling/COC services. 

Criteria for both 99222 and 99223 are identical with the exception of medical decision making. The history component for both is comprehensive (4+ HPI or status of 3 or more chronic conditions). Likewise, the examination is comprehensive (1995 guidelines requires 8 organ systems). The physician’s medical decision making for level 2 requires moderate complexity where level 3 requires high complexity. CMS publishes a medical decision making grid to work through each of these requirements.

When training physicians on subsequent hospital coding, I often use a backwards approach. Start with the condition of the patient and structure the documentation around the problem. Several years ago, CMS clarified the use of these codes by assessing the stability of the patient. The AMA later added this change to the CPT code criteria. Each subsequent hospital code references the following:

99231 Usually the patient is stable, recovering or improving

99232 Usually the patient is responding to inadequately to therapy or has developed a minor complication

99233 Usually the patient is unstable or has developed a significant complication or significant new problem.

From an auditing perspective, take a few inpatient charts and review the patient’s condition to see if documentation matches up. This may be an opportunity to coach your physicians on when they may be over-documenting for stable patients and under-documenting to meet the level 3 criteria. Remember—only two out of three criteria between history, examination and medical decision must be met to satisfy a subsequent hospital CPT code!

Lastly, don’t fall short on coding if your physician is spending several different times during the day rounding on the same patient. Last year, CPT revised the definition of prolonged care for inpatient services to read as follows: “Codes 99354-99355 are used to report the total duration of face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician on that day is not continuous.” If a physician is rounding multiple times on the same patient, same date, not only can all the documentation be used to code for a subsequent hospital service, the time component (if documented) may be 30 minutes over and above the CPT subsequent time and qualify for the additional prolonged service code. Keeping your physician staff informed on these coding requirements and periodically auditing their documentation will help keep them in compliance with the federal programs and private payers.

Written by Jana Gill, MA, CPC