Published in the April 2011 issue of Today’s Hospitalist
SINCE THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) did away with consult codes in January 2010, the initial hospital care codes (99221- 99223) have been getting a lot more play.
That’s because prior to that change, only admitting physicians used those codes, while everyone else had to use either the consult or subsequent hospital visit codes. Now, however, admitting physicians are no longer the only ones reporting initial visit codes. For claims submitted to the CMS (or to payers who follow its lead), initial visit codes should now be used for either the initial visit by a provider or the first visit by a provider within one group, regardless of whether or not he or she is the admitting physician. Because these codes are getting so much more traffic, it’s more important than ever to make sure you understand what’s required to bill higher-level initial care codes.
Stop using the term “noncontributory” for past history. If you’re set on using it, write “asked and noncontributory” instead.
Unfortunately, I see hospitalists making a lot of mistakes documenting these codes. When hospitalists fail to fully document a comprehensive history, they can’t support billing anything higher than a level-one initial visit, no matter how complex a patient’s condition may be. (You’ll be able to bill only a 99221 if you miss even one required element.) The number of relative value units (RVUs) for a level-three initial visit (99223) is almost twice that of a level one, so getting your documentation wrong makes a big difference to the bottom line.
Here are the basics requirements for a comprehensive initial hospital care history. In addition to the chief complaint, you need to document:
- four elements of the history of the present illness (HPI);
- a review of at least 10 systems (ROS); and
- one element each of the past, family and social history (PFSH).
The following tips will help make sure your history documentation supports the level of initial hospital care you provide.
History of present illness (HPI)
The No. 1 mistake I see is physicians falling short on the history elements. Get in the habit of documenting four elements of the HPI for every initial visit (and for every subsequent visit, for that matter) out of the following eight:
- location (where the problem is located);
- quality (sharp, dull, throbbing, stabbing pain);
- severity (measured on a 1-10 scale);
- duration (how long have symptoms been present);
- timing (course of symptoms, such as do they come and go);
- context (what patient was doing when symptoms began);
- modifying factors (what does patient do to make symptoms worse/better);and
- associated signs and symptoms (such as nausea or fever).
Keep in mind that if you document four signs and symptoms, you’ve met the requirement for only one HPI element (associated signs and symptoms). You still need to document three more out of the seven remaining to qualify for a comprehensive HPI.
You don’t, however, have to document four elements for each comorbidity the patient presents with. The four HPI elements you document can all relate to the patient’s chief complaint, or they can be a combination of elements relating to the patient’s different conditions.
Review of systems (ROS)
A complete ROS entails reviewing at least 10 systems and documenting all pertinent positive and negative responses. If you’ve performed a complete review of systems, you can use the following shortcut statement: “All other systems reviewed and are negative.” This shortcut saves you from individually documenting the results from all 10 systems while still establishing the fact that you performed a complete review.
However, statements such as “ROS negative except as above” or “All other systems reviewed are negative” do not support a complete ROS. That’s because they don’t clearly indicate that a review was performed, so make sure you’re not using this language.
Past, family and social history (PFSH)
One common mistake physicians make is not documenting one element each for the past, family and social history. As simple as this requirement sounds, many records fail to meet it.
Instead, physicians tend to pile on additional elements of the patient’s past history, thinking they’re meeting all the PFSH elements. Physicians will, for example, write the following:
Allergies: No known drug allergies. Past medical history: None significant. Past surgical history: Positive for recent status post appendectomy. Medications: Cipro 500 mg 1 tablet po BID.
Yes, you addressed four different areas, but all are elements of the past history. You still need to document at least one element for both the family and social history to be reimbursed for a level-three initial visit.
Another common error: writing “noncontributory” for the past history “a term that most auditors will not give you credit for. That’s because it’s not clear from your documentation whether you asked about past history or if you just thought it didn’t contribute to the present condition, and documented it as such.
I recommend that you stop using the term “noncontributory” altogether. If you’re set on using it, write “asked and noncontributory” to make sure you receive credit.
Finally, with patients for whom you can’t obtain a history due to their condition (they’re intubated, for example), be sure to explicitly document the reason you’re not including the history. Documenting “History not obtainable due to intubation” is fine.
As long as you state why you couldn’t obtain the history, you should receive full credit for each HPI, ROS and PFSH element of a comprehensive history. But just writing “history unobtainable” without giving a specific reason won’t do.
Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at firstname.lastname@example.org. We’ll try to answer your questions in a future issue of Today’s Hospitalist.