Subsequent Hospital Care (99231-99233)

These codes are used to bill for subsequent hospital care services known to all physicians as hospital progress notes.  There are three levels of care for this type of encounter which all require qualifying documentation of two out of three key components. Most physicians over-document and under-code for these services. You can break this pattern by reviewing below.

Level 3 Hospital Progress Note (99233)

The 99233 represents the highest level of care for hospital progress notes.  This is the second least popular code selected by internists who use the 99233 for 27% of these encounters.  Usually the patient is unstable or has developed a significant complication or a significant new problem.

The documentation for this encounter requires TWO out of THREE of the following :

1)    Detailed History
2)    Detailed Exam
3)    High Complexity Medical Decision-Making

Or 35 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included.

A detailed history for a level 3 hospital progress note (99233) would require:

1)       a chief complaint,

2)       an extended HPI

§         four HPI elements OR the status of three chronic or inactive problems - if using the 1997 E/M guidelines), 

§         and  two to nine elements of  ROS. 

3)      You don't have to include any PFSH.

1997 Detailed Exam requires at least 12 bullets from any organ systems.

At least 12 bullets from any organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or digital cyanosis
Skin: no rash, lesions or ulcers
Psych: Alert and oriented to person, place and time

(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for examination of neck)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for assessment of carotid arteries)
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
(1 bullet for examination of extremities for edema)
(1 bullet for examination and/or palpation of digits and nails)
(1 bullet for inspection of skin and subcutaneous tissue)
(1 bullet for brief assessment of mental status—orientation)

Total bullets = 12

High Complexity Medical Decision-Making truly is complex.  Either the patient is quite ill or the physician must review a significant amount of primary data.  This level of MDM is required for a level 3 hospital progress note (99233).  The patient would need to have a severe exacerbation of a chronic problem or an acute illness which threatens life or bodily function to qualify for this level of risk.  The data reviewed would have to be quite extensive to reach the threshold for high complexity MDM.

High MDM Requires two out of three of the following:

1)   Four problem points based on problem point table below
2)   Four data points based on the data table below
3)   High risk

The “nature and number of clinical problems” are quantified into Problem Points by referring to the following table:

The above table is fairly self explanatory.  An “established problem” refers to a diagnosis which is already known to the examiner, such as hypertension, or diabetes.  An example of a “new problem with no additional work-up planned” may be a new diagnosis of essential hypertension.  Examples of “new problem, with additional work-up planned” may include any new clinical issue which requires further investigation such as proteinuria, anemia, shortness of breath, etc

Coding Tip: Problems which are not being addressed specifically by the physician during the encounter may still be counted if they significantly increase the complexity of the cognitive labor required.  For example, consider a patient with diabetes who is being evaluated by a nephrologist for CKD evaluation.  It would be appropriate for the nephrologist to include diabetes as an “established problem, stable” when calculating the problem points.  This is because the comorbidity of diabetes does significantly influence the risk of CKD and the complexity of the management.

Coding Tip: Problems are defined relative to the examiner, not the patient.  Even if the problem was previously known to other physicians or to the patient, it is still considered new to you if you are seeing the patient for the first time. This situation arises often in the case on consultations.

Data Points: The “amount and complexity of the data points reviewed” are quantified by referring to the following table:

The physician should be aware that no “double dipping” is allowed.  For example, if you review lab results and order labs during the same visit, you only get one point (not one point for ordering and one point for reviewing).  This same rules applies to imaging studies or other medicine tests such as EKGs or Echos.  Commonly overlooked points are those garnered for obtaining or reviewing old records.  If you do review old records, you must summarize your findings in the chart.  It is not acceptable to just say, “Old records were reviewed.” 

Coding Tip: Notice that points can accumulate quickly if you personally review an image, tracing or specimen.  You can still claim these points, even if the image, tracing or specimen has been reviewed by another physician (as when a radiologist provides an official interpretation for an X-ray).  However, you must include your own interpretation in the chart in order to claim these points.

High Risk: This is the highest level of risk.  This level of risk is required for a level 3 hospital progress note (99233).

This level of risk requires ONE element in ANY of the following three categories:

Presenting Problem(s)

• One or more chronic illness with severe exacerbation or progression

• Acute or chronic illness or injuries which pose a threat to life or bodily function (e.g.,
  multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive
  severe rheumatoid arthritis, psychiatric illness with potential threat to self or others,
  peritonitis, acute renal failure)

Diagnostic Procedure(s)

• Cardiovascular imaging studies with contrast with identified risk factors

• Cardiac EP testing

• Diagnostic endoscopies with identified risk factors

• Discography

Management Options Selected

• Elective major surgery with identified risk factors

• Emergency major surgery

• Parenteral controlled substances

• Drug therapy requiring intensive monitoring for toxicity

• Decision not to resuscitate or to de-escalate care because of poor prognosis 

Clinical Example 1

A patient with worsening acute renal failure following CABG

CC : Follow-up ARF

Interval History: The patient’s ARF has worsened since yesterday and he has become oliguric.  Hypotension has resolved and in fact the patient is somewhat hypertensive today.  He is POD #4 from four vessel CABG.  Coronary disease has been stable with no evidence of ongoing ischemia.

Medications

Sliding scale insulin Coreg 12.5 PO BID , Lasix 40 mg PO QD , KCL prn, per protocol

ROS 

General--Positive for fatigue ; gative for fevers/chills
Cardiovascular—Positive for worsening edema; negative for chest pain, orthopnea or PND
GU-- Negative for flank pain, hematuria, dysuria, obstructive symptoms

Physical Exam

General: NAD, conversant, but somewhat anxious
Vitals: 160/90, 65, 98.6
HEENT: OP clear with MMM, No JVD
Lungs: CTA in front with faint bibasilar crackles in back
CV: RRR, with healing midline sternotomy
Extremities:  3+ bipedal edema; no digital cyanosis
Skin: Warm and dry with normal turgor; new rash or levido reticularis
Psyche: A&O times 3, with appropriate affect

Labs: BUN 67, creatinine 3.8, K 5.7, HCO3 18, HGB 9.0, BNP 1750

Assessment 

1. Worsening oliguric ARF with hyperkalemia and metabolic acidosis

2. Decompensated cardiomyopathy with evidence of CHF on exam

3. Poorly controlled hypertension

4. Worsening anemia

5. CAD s/p CABG

Plan

1. Stop oral furosemide

2. Start bumex 2 mg IV Q6

3. Chest X-ray in a.m.

4. Recheck renal profile and CBC tomorrow

5. Consider transfusion if HGB drops below 8.5

6. No indication for dialysis today

7. Patient and family updated at the bedside

The clinical example qualifies as a Detailed History.  Usually this level of history must include one element of PFSH, but this requirement is waived for hospital progress notes .  Therefore in this case a Detailed History requires only a chief complaint, an extended HPI consisting of four HPI elements (or the status of three chronic problems--if using the 1997 guidelines) and an extended ROS (review of two to nine systems).  In the example, the status of three problems (ARF, CAD and hypertension) are used to satisfy the HPI requirements using the 1997 E/M rules.  A review of the constitutional, cardiovascular, and GU systems satisfy the requirement for two to nine ROS.  All the elements of history included are probative and clinically relevant in keeping with the intrinsic medical necessity of the encounter.  Notice that even though no PFSH is required for this particular Detailed History, a review of the patient’s medications would technically count as one element of PFSH .

Coding Tip : The 99233 should probably be used more often by all physicians.  In the above example, High Risk is obvious and is used as a qualifying component of High Complexity Medical Decision-Making, but it is not necessary that every patient assigned this code be High Risk.  Often, the Data Points can add up quickly in the hospital (especially if you personally review an image or tracing).  In these cases the Data Points can be added to the Problem Points to qualify for High Complexity Medical Decision-Making.  Physicians are urged to systematically calculate the Medical Decision-Making for every encounter in order to recognize and take credit for their cognitive labor.