Published in the August 2012 issue of Today’s Hospitalist
HOSPITALISTS ARE ALL TOO FAMILIAR with “coder’s triad“: history, physical examination and medical decision-making. We mix and match these three components to come up with service levels of E/M coding. The initial hospital care (99221’99223) and subsequent care (99231’99233) series represent the final pathways for various permutations of clinical data, medical decisions and risk.
Hospitalists are also generally aware that they can bill based on time. While seemingly attractive “think of that chatty patient or family member who won’t let you escape “there are caveats and headaches that reduce its utility.
Then there is a parallel coding universe that gets completely neglected in hospital medicine: V codes. According to ICD9, these codes are a “supplementary classification of factors influencing health status and contact with health services.” V codes are primarily used for encounters other than illness or injury, so how would they apply to our sick patients?
Let’s take a look at both billing for time and V code options.
Game with minutes
To bill based on time, you must spend more than 50% of the total encounter counseling and/or coordinating care. The total number of minutes needs to be documented (that’s the key word), and you should describe what actually occurred.
Take, for example, a patient readmitted yet again for decompensated heart failure. After rescuing him from drowning, you spend the bulk of a follow-up visit on counseling. At the end of your daily progress note, which might be brief, you could indicate:
Total time: 40 minutes. Of this time, greater than 50% was spent counseling. Counseling elements included education about the natural history and management of heart failure. The importance of diet, fluid restriction and medication compliance were explained and underscored.
That little paragraph supports a 99233, which is worth about $97 in Medicare money. (See “E/M codes: payment and time thresholds,” below). If you forget to include something like this in your documentation, your charge will be based only on the coder’s triad, which generally winds up paying a lot less for a reasonably stable patient.
Counseling conjures up images of psychotherapy “couches, Rorschach blots, lots of Kleenex “but these are very different services. According to the AMA’s Current Procedural Terminology (CPT), counseling involves discussing with the patient and/or family one or more of the following:
- diagnostic results, impressions and/or recommended diagnostic studies;
- risks and benefits of management/treatment options; instructions for management/treatment and/or follow-up care;
- importance of compliance with chosen management/treatment options;
- risk factor reduction; and
- patient and family education.For counseling to contribute to the level of service, you must conduct it face-to-face with the patient. Telephone conversations with family members don’t count; ditto for family care conferences if the patient is absent. There is, however, one very important exception: Hospitalists can bill for time spent planning treatment with families when patients are physically incapable of participating in the discussion.
Coordination of care
CPT does not categorically define “coordination of care.” But we know it when we see it. It relates to discussing and organizing treatment and management needs with a patient or other clinicians, facilities or community resources. Taking report from the patient’s nurse or calling a cardiologist meets muster. Calling a family member in Manitoba, even if he or she is a nurse or cardiologist, not so much.
Billing for coordination of care requires the same documentation as counseling. You need to document the total length of the encounter and specify that more than 50% was spent coordinating care. You should also describe the coordination of care elements.
In practice, counseling and coordination of care often occur during the same encounter. Take, for example, a patient with hopeless cirrhosis. Your daily progress note to support a 99232 might include the following:
Total time: 25 minutes. Of this time, greater than 50% was spent counseling and coordinating care. Counseling elements included educating the patient about avoiding alcohol and taking his liver failure medications. Coordination of care elements included treatment planning with the hospice team concerning end-of-life care.
We’ve recently heard some hubbub about unit/floor time and how it contributes to your level of service. Doctors find this entire subject very confusing because unit/floor time does count toward billing initial and subsequent hospital care “but not toward billing prolonged services. (These are services that exceed the average amount of time associated with any particular level of service by at least 30 minutes.)
By definition, unit/floor time includes the total time spent on the patient’s hospital unit, including time at “and away from “the bedside. Reviewing medical records, reading X-rays, charting, and communicating with other clinicians and family members all fall under this umbrella. These activities are billable, which is great news for hospitalists because we spend the minority of our time at bedside.
But here’s the rub: While CPT recognizes unit/floor time for both inpatient services and prolonged services, the Centers for Medicare and Medicaid Services (CMS) does not. The CMS allows you to count unit/floor time toward your choice of initial or subsequent care code but not toward billing for prolonged services.
Why? Because only direct face-to-face contact between the physician and patient (whether or not that was continuous) counts for prolonged services, and a lot of unit/floor time occurs outside the patient’s presence. Basically, our unit/floor care is a giveaway when we exceed the time threshold for the various levels of initial or subsequent care.
V codes are strange animals that come into play under four circumstances:
- people who are not sick or injured receive medical care for some specific reason;
- patients who require ongoing care for resolving illness, injury, disease or long-term/chronic medical problems;
- patients with circumstances or problems that influence their health status who are not currently ill or injured; and
- care delivered to newborns.
You can use some V codes as primary diagnoses. Pediatric hospitalists, for example, can invoke a whole slate of these codes for following healthy babies from delivery to discharge (V30’V39). All hospitalists can tap into the codes for palliative care (V66.X), ventilator weaning (V46.13) and caring for organ donors (V59.X). A few bizarre codes include “suspected exposure to anthrax” (V71.82) and “encounter for ventilator dependence during power failure” (V46.12). We refer to the latter as BYOA “bring your own ambu “and hope you never need it.Many other V codes can be used as secondary diagnoses. “Bariatric surgery status” (V45.86) can support the need for surveillance laboratory studies, for example, while V44.X, which refers to “artificial opening status,” can justify ostomy care. But word to the wise: Check with your friendly neighborhood coder about the appropriateness and sequencing of these codes. Some get pretty tricky.
David Frenz, MD, is a hospitalist for HealthEast Care System in St. Paul, Minn., and is board certified in both family medicine and addiction medicine. You can learn more about him and his work at www.davidfrenz.com. Sue A. Lewis, RN, CPC, PCS, is a compliance consultant with HealthEast Care System.