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New CPT codes for 2006, and shortcuts to document a review of systems

February 2006

Published in the March 2006 issue of Today’s Hospitalist

Q: What changes in CPT do we have to look forward to in 2006?

A: 2006 brings a major change in the evaluation and management codes: the deletion of the follow-up inpatient consults (CPT 99261-99263).


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Follow-up inpatient consult codes were created to give physicians a way to describe secondary consults in which they were being requested to suggest a new plan of care. In many instances, however, this concept was confusing. Physicians and coders alike often had difficulty differentiating when physicians were providing traditional follow-up care as opposed to being “re-consulted” for an entirely new plan of care.

Follow-up inpatient consults were never meant to replace the subsequent hospital visits (CPT 99231’99233) normally billed in the course of a patient’s stay. Because the inpatient follow-up codes were frequently misused, however, federal officials began to target physicians who used this code series repetitively.

According to the latest version of CPT, we are now instructed to use subsequent hospital visit codes (CPT 99231’99233) to code for all and any follow-up inpatient hospital care.

There is one caveat, however. You may still be able to use critical care codes, as long as you can document medical necessity and you spend more than 30 minutes coordinating critical management of care.

Q: Can I document “rest of review of systems unremarkable” and count that toward a complete review of systems?

A: Guidelines from the Centers for Medicare and Medicaid Services say that to qualify for a complete review of systems, physicians must inquire about 10-plus organ systems.

While this rule may seem unnecessary, you should think twice before you skimp on the number of systems you check. Failing to document a complete review of systems can take you from a 99223 to a 99221 inpatient hospital admit in an instant, drastically reducing your reimbursement!

When dictating a review of systems, however, there is an important caveat to keep in mind. You must provide documentation on two pertinent, positive organ systems, but you can then make a statement stating “all other systems reviewed and negative.”

Make sure you avoid such vague terminology like “noncontributory” to describe your review of systems. Also avoid referring to the history of the present illness (HPI) to flesh out your review of systems.

I know that physicians often think they can tackle the entire review at the bottom of the HPI, but I often see review of systems documentation that falls short of 10 systems. Generally, these reviews of system merely repeat a few of the same systems. Don’t fall prey to this costly mistake!

Q: Can attending physicians in teaching hospitals refer to their residents’ history and physical forms and then count that towards their own billing level? Exactly how extensive and explicit must attendings’ comments be?

A: Medicare guidance 1780, which was issued in November of 2002, outlines several changes in this area. This guideline says that attending physicians should be involved in the key portion of the history, exam and medical decision-making. In the inpatient setting, residents and attendings can examine the patients at different times of the service.

Attendings must provide an attestation statement that states the patient was seen and examined by the attending, in conjunction with a resident, referring to the resident’s history and physical. The attestation statement should also elaborate on any further medical decision-making, history or exam.

Tamra McLain is coding manager for HRA Medical Management Inc. in San Diego. E-mail 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.