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More questions—and answers— about observation and inpatient consultation codes
by Tamra McLain, CPC, CPC-H, CMC



Published in the October 2005 issue of Today's Hospitalist

In your last column (“Answers to questions about timing for discharge and observation codes,"), you note that when coding for patients who have died in the inpatient setting, hospitalists should use discharge services codes. I recently saw that Cigna, the insurance company that administers Medicare in my area, has published guidance that contradicts that advice. What should I do?

Since that article on discharge and observation codes was published, I have received several e-mails requesting further clarification on the issue of using discharge services codes (CPT codes 99238-99239) for expired patients.

I based the advice in my column on guidance from the AMA, which created the CPT codes. When I checked into your concerns about the policies of Cigna, I did indeed find an article from May/ June 1999, “Hospital Discharge with Expired Patient,” which rebukes the idea of using discharge services codes for patients who have died. That article directs physicians to use subsequent visits or critical care codes, whichever is more applicable.

In May 2004, however, Cigna issued a new bulletin that states the following: “There is no specific code for the pronouncement of death. To be reimbursable by Medicare, a service must be billed using the CPT code that most accurately describes the work performed. Accordingly, this carrier will accept the code that best describes the services rendered to an individual patient during the pronouncement of death. This may include the hospital discharge codes (CPT codes 99238-99239), as long as the provisions of the code descriptor are met as documented in the medical record. This article supersedes the article ‘Hospital Discharge with Expired Patient,’ published in a previous Medicare Bulletin, General Release May/June 1999”.

While Cigna has changed its policy on discharge service codes for patients who have died, your question illustrates an important point: Physicians need to check the guidelines of their local carriers for regulations. When dealing with Medicare carriers (in your area, companies like Cigna), you need to follow their guidelines for Medicare patients, even if that contradicts CPT’s rules and procedures.

In that same article on observation services codes, you wrote the following: “While observation services are not specifically based on time, the admit and discharge date must fall on the same calendar day.” This doesn’t seem correct. Can you elaborate?

You’re right that this statement is not entirely correct. What I meant to convey was that if a patient is admitted and discharged on the same day, you should use one set of codes (CPT codes 99217-99220). If that patient’s time in an observation service occurs over multiple calendar days, you should use another set of codes (CPT codes 99234-99236).

Is it OK for a provider to indicate that a family history is “noncontributory?” Can you do the same thing when performing a review of systems?

The term “non-contributory” has always been considered controversial. It raises the bigger question of whether a physician actually asked the patient about his or her family history and found nothing, or whether the physician didn’t think the question was relevant and decided against asking about family history altogether.

As a result, most of my colleagues in medical coding recommend staying away from the statement. Many worry that if you use this term and undergo an audit, your documentation for that patient won’t hold up under scrutiny.

One practice I recently talked to uses a slight twist on the phrase that might get around this problem. In this group’s documentation, coders note that a question about family history was “asked and is non-contributory.” This tells anyone reviewing your records that the appropriate questions were indeed asked and that the findings were not relevant to care.

Regarding the review of systems, there is a caveat to help shorten the documentation process for a complete system review. Coding and documentation rules say that two positive pertinent systems must be reviewed and documented, and that “for the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.” Note that negative, not non-contributory, is the key phrase in this caveat.

When is it appropriate to use follow-up inpatient consultation codes (CPT codes 99261-99263)?

Physicians often think that follow-up inpatient consultation codes are synonymous with subsequent hospital visit codes, which is a mistake. These codes are in fact very different and should not be used interchangeably.

CPT provides instructions about when to consider codes for follow-up consultations. Those guidelines state the following:

* Use to complete the initial consultation or subsequent consultative service requested by the attending.

* Can include monitoring progress, recommending management modifications or advising on a new plan of care in response to changes in the patient’s status.

* If the patient has initiated treatment with an initial consult, and participates in the patient’s management, refer to subsequent hospital visits (CPT codes 99231-99233).

* Use for patients in the inpatient setting or for nursing facility residents only.

You can choose from three CPT codes for follow-up consultations. See “A review of CPT’s three codes for follow-up consultations,” on the previous page, for the documentation requirements for these codes.

Tamra McLain is coding manager for HRA Medical Management Inc. in San Diego. E-mail her your documentation and coding questions or send a fax to 619-280-1347. We’ll try to answer your questions in a future issue of Today’s Hospitalist.


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