Questions and answers about coding for subsequent visits and discharge management

Questions and answers about coding for subsequent visits and discharge management

November 2006

Published in the November 2006 issue of Today’s Hospitalist

I received several questions from readers, some of which pertained to my two previous columns on billing for subsequent visits and for time spent counseling. Here are those questions with my responses:

Billing for subsequent visits

Q: In the Seven mistakes to avoid when billing for subsequent visits”, you indicated that you could bill for a level 3 subsequent visit (99233) only if the patient is “deteriorating.”

I can understand that multiple chronic problems may not be billed as 99233, but what about multiple current acute problems?

A: The service could qualify as a level 3 if the patient is still severely ill and the treatment is complicated by multiple serious acute problems, even if some of those may be resolving.

Q: According to your article, your documentation may support only a level 1 subsequent visit (99231) if you can’t document at least one review of systems.

However, you also point out that “CPT guidelines require you to meet only two of three components: interval history, exam and decision-making.” Because a review of systems is part of the interval history, couldn’t you document both the exam and your decision-making, and still be able to bill for a level 3 subsequent visit?

A: You are correct. You can rely on your exam and medical decision-making and not worry about your history. But in cases where you don’t perform a detailed exam, you may have to rely on your history to support billing for more than a level 1 visit.

Q: We work with intensivists in a “non-closed” ICU model, and I have always wondered how that affects our billing for subsequent visits. Do we run a risk of “double billing” for the same patient?

And does the presence of intensivists affect the way the Centers for Medicare and Medicaid Services (CMS) looks at our coding and billing?

A: If the intensivists are part of your group and practice under the same tax ID number, seeing the same patient for the same condition may be an issue, particularly on the same date of service. Your carrier may question the medical necessity of multiple visits, and you would need to be able to justify the medical reason for both services.

If you and the intensivists are members of the same group and each need to manage different problems for the same patient, make sure that you clearly document the medical necessity in the patient’s record. The initial claim may be denied, but you should be able to support your billing on appeal by sending in your documentation.

Counseling billing

Q: Can I charge for counseling in situations where the patient is incapacitated or unconscious, yet a family meeting is necessary?

I had always understood that I could bill for such counseling by calculating my time as you describe in your billing for counseling article. Does that mean I can’t bill counseling time if the patient is unconscious?

A: If the patient is unconscious or otherwise incapacitated, and it is medically necessary for the physician to speak with the family to get information for diagnostic or treatment purposes, then it would be a billable service. The service must be appropriately documented in the record and meet the counseling guidelines. Some experts advise that you remain in the presence of the unconscious patient to bill Medicare for counseling.

If, on the other hand, you are meeting with family members to update them on the patient’s progress or status, or to counsel them without the patient being present, then the counseling is not medically necessary.

Hospital discharge management

Q: May I use a 99239 code for hospital discharge management that takes more than 30 minutes if one of my partners completes the majority of the discharge paperwork?

We often try to prepare for upcoming discharges ahead of time by completing order sets and discharge summaries to reduce the workload during patient hand-offs. I frequently spend 30 or more minutes preparing for a discharge that is then completed the following day by one of my partners.

A: As long as you are the only one billing for discharge management and a partner’s work at discharge isn’t part of any other billed service, you can include your partner’s work at discharge as part of your bill. You can bill the discharge management code only once per hospital stay, on the day of the actual discharge. You cannot bill for a subsequent hospital visit on that day, in addition to the discharge code.

Medical decision-making

Q: When choosing the level of a service visit, we always used to count discussing the case with the nurse as two points towards the amount of data ordered/reviewed section of the medical decision-making portion.

However, where I now practice, I’m told that such a discussion must be with another physician. What’s the right answer, and are there any guidelines I can use?

A: CMS guidelines do not offer any credit toward “amount of data ordered/reviewed” for a discussion with a nurse. However, those guidelines do offer credit toward “amount of complexity and data” for several items, including the following:

“¢ a discussion of contradictory or unexpected test results with the physician who performed or interpreted the test, as an indication of the complexity of the data being reviewed.

“¢ a decision to obtain either old records or additional history from the family, caretaker or other source to supplement information obtained from the patient. That decision must be documented.

“¢ relevant findings from your review of old records or the additional history from the family, caretaker or other source to supplement patient information. Again, you would need to document those relevant findings.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at We’ll try to answer your questions in a future issue of Today’s Hospitalist.