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What you need to know to document an initial hospital visit
Skimping on documentation can sabotage how much you get paid for a comprehensive history and exam



Published in the January 2007 issue of Today's Hospitalist.

When it comes to choosing a code for an initial hospital visit (99221-99223), you have three choices, based on whether you use low, moderate or high decision-making. But choosing your level of decision-making for these codes should represent the tail end of a much longer process.

Unless you're planning on billing only a level 1 hospital admission, you need to perform a comprehensive history and exam. And for billing purposes, it's just as important that you document that history and exam to support your level of decision-making. Otherwise, you may not be
Get in the habit of always documenting four elements of the history of present illness.

appropriately reimbursed for the time and effort you put into a patient's initial visit. Or your documentation may not support the service you bill and could result in an overpayment.

Here are some general guidelines to help you appropriately document the patient's history and exam-and make sure you get the right level of reimbursement.

General ground rules
When choosing an initial hospital visit code, here are some general rules to follow:

  • You must meet or exceed the performance requirements for a comprehensive history and exam if you plan to bill for anything higher than a level 1 visit.
  • Only the admitting physician can bill for the initial hospital visit code.
  • That initial visit code can be used only once during a patient's hospitalization.
  • Reimbursement for the initial hospital visit includes all evaluation and management services provided by you or a member of your group on the same day. Make sure each physician fully documents his or her level of history, exam and decision-making.

Documenting the history
A comprehensive history includes the following: at least four elements of the history of present illness; a review of 10 systems; and a past, family and social history.

A detailed history for a level 1 initial visit, on the other hand, consists of four history of present illness elements; at least two systems reviewed; and one element of the past, family and social history.

Get in the habit of always documenting four elements of the history of present illness. That way, you won't fall short in the history of the present illness category required for both a detailed and a comprehensive history. Documenting four elements also helps paint a clear picture of what is going on with the patient ands supports the code you choose.

If you have performed a complete review of systems, you can use the following short-cut statement: "All other systems negative or WNL [within normal limits]." That short-cut helps reduce the amount of documentation you need while still establishing the fact that you performed a complete review of systems, even when you don't document all 10systems. But keep this caveat in mind: You should use this statement only after you have documented all individual, pertinent positive and negative responses.

What if you can't get a history because of the patient's condition, such as when a patient is in a coma or intubated? You can still get credit for a comprehensive history, as long as you document why you couldn't obtain the history.

Make sure you include that documentation, even if the reason seems obvious from the medical record. Don't just write "history unobtainable." Instead, document the reason, such as "patient comatose" or "patient intubated."

Documenting the exam
To demonstrate through documentation that you've performed a comprehensive exam, you can count only organ systems.

(For an exam that is not comprehensive, you can count body areas and/or organ systems.) Most auditors agree that a comprehensive exam should include the examination-and documentation-of eight different organ systems.

You can include a constitutional statement as either part of your exam documentation or part of the history review of systems documentation, but not both. If you are considering including your constitutional review as part of your exam, make sure you include a statement in your exam documentation such as "vitals WNL," or simply re-state the vitals. Some coders and auditors will not give physicians credit for the constitutional exam unless they make a statement acknowledging that they have reviewed the vital signs.

And make sure you don't shortchange yourself when documenting your examination of the eyes, ears, nose and throat. Many times, I see physicians include this notation in their documentation: "HEENT-tympanic clear." Because the statement covers only the ears, physicians will not get credit for examining the patient's eyes.

Instead, you should state, "HEENT-tympanic clear, all others negative." That way, you can claim credit for examining the eyes and get a point for examining the head, if body areas are being counted.

Finally, when documenting your exam, keep in mind that you have to include a statement for each area examined with a positive finding and indicate a negative response for each area where there were no relevant findings. (You can't, in other words, state "all other areas negative in the exam.")

Otherwise, you will lose credit toward doing a comprehensive exam and may have to settle for a lower level of reimbursement.

Decision-making complexity
Remember, CPT's definition of medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the following:

  • the number of diagnoses and management options that must be considered;
  • the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and
  • the risk of significant complications, and/or mortality as well as co-morbidities, associated with the patient's presenting problem(s), diagnostic procedure(s), and/or possible management options.

Documenting your decision-making is a key element in supporting the level of initial hospital visit you bill. Look for my column in the March issue of Today's Hospitalist for tips on decision-making documentation.

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