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Seven mistakes to avoid when billing for subsequent visits

September 2006

Published in the September 2006 issue of Today’s Hospitalist

Related article: ICD-10 surprises in the hospital.

When it comes to billing for subsequent visits (CPT codes 99231-99233), many hospitalists make some relatively simple and “avoidable” mistakes.

Some errors stem from insufficient documentation and can lead to payments being denied or downcoded. Even worse, a pattern of picking the wrong subsequent visit codes may set you up for an audit.

Bill the highest subsequent visit level—99233—only for patients with a deteriorating condition. 

What to do? When billing for a subsequent hospital visit, you need to choose the appropriate level of service based on the patient’s condition and then make sure your documentation supports that choice. Here’s a list of what can go wrong “and some tips to help you avoid mistakes.

Picking the wrong code. One of the most common mistakes hospitalists make is billing for a higher level of subsequent visit than the documentation and service can support.

Bill the highest level “99233 “only for patients with a deteriorating condition, backed up by your diagnosis and documentation. If the patient is deteriorating, you need to say so clearly in your note.

A stable patient, even with multiple chronic conditions, does not qualify for a level 3 subsequent hospital visit. And if you can’t document at least one review of systems (ROS), the highest level of subsequent visit your documentation may support is a level 1 (99231).

“Clustering” subsequent visit codes. Another big mistake is using the wrong billing pattern.

Billing several level 3 (99233) visits in a row followed the next day by a discharge code, for example, could set you up for an audit. As noted above, only unstable patients meet 99233 criteria, and you wouldn’t expect those patients to be discharged the next day. (See “A scenario of subsequent visit codes” for a coding pattern that won’t set off auditor alarms.)

Skimping on history documentation. To bill a subsequent hospital visit, CPT guidelines require you to meet only two of three components: interval history, exam and decision-making.

But giving details in your history of how the patient is responding “such as “worsening,” “uncontrolled,” “stable” or “improving” “can be key indicators of the service level provided. You also need to document new complaints or symptoms to demonstrate decision-making complexity and to help support a higher level of service.

Not restating why you’re seeing the patient. You’ve seen the patient several times during her hospital stay, so you don’t need to keep documenting why you’re seeing the patient, right?

Unfortunately, that’s not the case. Even if your current note appears directly above your documentation for a previous date of service, you must state the reason why you are seeing the patient
and the reason for the service to establish medical necessity. Unless the documentation for each date of service can stand alone and support the service billed, your bill for a subsequent visit may be denied.

Being too vague about follow-up. Another frequent documentation error: stating the reason for the visit is “follow-up,” without elaborating on what it is you’re following. Noting “follow-up” without documenting the patient’s specific condition could render the visit non-billable because, again, the medical necessity cannot be justified.

So don’t be vague. When following up on a patient, state “follow-up” and then the condition you’re monitoring, such as “follow-up CHF.”

Not referring specifically to a previous history. Coders or auditors can rely only on your documented notes for the date of service they are reviewing. But they can use history that you’ve previously documented “as long as you’ve specifically referenced the date the history was taken and given an update. A coder or auditor can then apply the previous history toward your level of history in the current note.

To avoid having to restate the previous note’s history, refer to that note directly. Acceptable versions include “history unchanged since [insert the date of the previous service note] or “[previous date of service] history reviewed, no changes except …”

Documenting “noted above” or “history unchanged” without specifically giving the previous note’s date won’t suffice. Another way to improve the quality of your documentation is by updating the ROS obtained when the patient was admitted, as in “ROS unchanged from [insert date of admission] admission note.”

Ignoring daily concurrent care. Concurrent care becomes a real medical necessity issue, especially when several physicians are rounding on the same patient.

Keep in mind that a subsequent hospital visit represents the services provided during an entire day–and that you can bill only one subsequent visit per day. Even if the physicians in your group bill more than one subsequent visit each day, only one subsequent visit bill will be paid.

Make sure your subsequent visit bill for any given date includes all the services rendered by providers of the same specialty within your group. Combine all visits during one calendar day and select the code that reflects the level of all the work provided.

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.