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Bells and whistles

October 2008

Recently, my hospital decided to switch coding software. Just when I was getting comfortable with the old one, in comes the new, niftier software that will capture 100% of charges and thereby boost reimbursement.

At about the same time, we reviewed our charges for the previous year and found some interesting results.

Without going into details (to avoid anti-trust accusations), I discovered that there is a bit of variety in what people bill for the same conditions. This made me go back and review some of the coding requirements for in-hospital care.

Let’s take, for example, the initial hospital day codes: 99221, 99222 and 99223.

Three components go into deciding which level of code to bill: medical decision-making, history and examination. The degree of care–and the level of code–depend on the complexity of the decision-making, the elements of the history that are present and the comprehensiveness of the exam.

If the decision-making is straightforward, you bill a 99221; if it’s moderate, a 99222; if it’s high complexity, it’s 99223. Likewise with the history and examination: the more you do, the higher level of care you can bill.

At least that’s what the books say. What I’ve found is that all these elements can be a bit subjective.

(And the difference in dollars can be significant. According to the AAP Medicaid Reimbursement Survey Report for 2007-08, Kentucky Medicaid paid $51.66 for 99221, $85.60 for 99222 and $119.25 for 99223. In Virginia, where I used to practice, the difference is $70.02 for level 1, $94.83 for level 2, and $140.02 for level 3.)

So, let’s say you admit someone with asthma. To me, asthma is a pretty straightforward illness, although the management can be quite complex depending on the degree of severity.

Some people might say that because the management can be quite significant, it warrants a higher level of care. Others may tackle the issue from the angle of new onset vs. exacerbation of chronic disease. Others may focus more on the exam and the severity of the exacerbation. And still others will say, “Well, I’m in an academic institution, which automatically warrants a higher level of care code.”

The same subjective interpretation can apply to subsequent day codes. The only difference is that, from what I’ve read, the only way you can bill a level 3 subsequent day code is if the patient is really worse off than when he or she first came in or if a significant new problem develops. The discharge day codes are easier because they are time-based: either less or more than 30 minutes spent performing final discharge services.

Whatever thought processes you use to justify your coding habits, always remember this: If it’s not in the chart, you didn’t do it. Unfortunately, sometimes it’s more important what you document than what you actually did. Of course, I’m not suggesting you embellish the chart with descriptive paragraphs worthy of Proust. But make sure that whatever level of care you code, the documentation matches your actual work.

Is there a better way? Sure, but that’s way above my pay-grade. Plus, it’s an election year … Who wants to talk about universal health care? Oops … Oh well, there, I said it.

Either way, I’m enjoying my new coding software. At least it doesn’t beep when I enter the wrong code. It just politely flashes a little warning in red. Then it crashes.