Coding guidance on admission codes; subsequent care codes; and coding volume outliers.
Q: If a hospital admission code 99221-99223 is not supported - for instance, if it does not have enough HPI or exam to meet the lowest level of admit - can we use the subsequent 99231-99233 codes if they are supported?
A: Although there are some comments that suggest otherwise in the online claims manual, several Medicare carriers and Medicare Administrative Contractors (MACs) say you can do exactly that.
Please see the following federal contractor authoritative references that support this position. I hope they help you support your position.
Supporting carrier guidance: MAC TrailBlazer Health's website (www.trailblazerhealth.com) states that: "TrailBlazer recognizes provider reluctance to miscode initial hospital care as subsequent hospital care. However, doing so is preferable in that it allows Medicare to process and pay the claims much more efficiently. For those concerned about miscoding these services, please understand that TrailBlazer will not find fault with providers who choose this option when records appropriately demonstrate the work and medical necessity of the subsequent code chosen."
WPS guidance: http://bit.ly/WPSadvice
Subsequent Care Code
Q: If I am the admitting physician for a patient and today is the first day I see the patient but my documentation does not support the level of service for a 99221, should I bill an NOC code or should I bill a subsequent care code?
A: CMS instructs contractors not to find fault with a provider who uses a subsequent care procedure code, if the level of documentation does not support the procedure code. The use of the NOC 99499 should be very rare. See the Medicare Claims Processing Manual, chapter 12, Section 220.127.116.11.F http://bit.ly/NOCcode
Coding Volume Outlier
Q: We received a letter from our Medicare carrier suggesting that one of our providers is doing something wrong because he has a higher volume of some codes (99214s) than his peers. What is your impression of letters like this and what measures do you recommend that we take?
A: My first question is: Are nonphysician providers involved here? Does the "volume" the carrier is seeing reflect the work of more than one provider? If not, and your provider sees a lot of patients in a short time, CMS may suspect "churning." Volume profiles are different than coding profiles in that the normative data tends to be more meaningful because it considers limiting factors, such as time. In other words, a coding curve can't tell you how sick your patients really are, but a volume curve can suggest short visits or excessive numbers of visits.
You may want to consider having an internal peer look at multiple return visits on the same patient. That will help determine if churning is occurring. Consider whether patients are seen more than standard practice of care would suggest is necessary. Also consider if the problem could be due to practice style. If it is a practice style with more revenue incentive than medical necessity, then you have a problem.
Although an internal review of individual visits may not reveal any issues, consider conducting a review of longitudinal visits. That could turn up churning if you look into medical necessity.
CMS can't do anything beyond sending their letter and audit the code levels in question.
Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at firstname.lastname@example.org or email@example.com.
This article originally appeared in the October 2012 issue of Physicians Practice.