Complete Stay Audits

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Posts: 45
Joined: Fri Aug 03, 2012 10:22 am

Thu Aug 31, 2017 2:56 pm

Hi. I see there is an unanswered question posted on July 6 with this topic, and it prompted me to ask related questions as well.

Previously for coding of physician E/Ms in the hospital, my understanding is that each hospital E/M by the physician is coded based solely on its own documentation. For example, if a 99233 was billed on DOS 8/31, we would evaluate only the 8/31 documentation.

However, more recently I hear more and more of the 'need' to code or audit by "complete stay" for physician hospital services, rather than by the specific encounter, so some auditors look back at all of that physician's previous E/Ms for the patient's admission, as well as the E/Ms after the billed date up to and including the hospital discharge.

As an example, for the 8/31 99233, let's say an auditor is looking at 8/31 and then looking back to the 8/26 H & P, the progress notes on 8/27, 8/28, 8/29, and 8/30, then also at the progress notes on 9/1, 9/2, 9/3, 9/4, and the discharge summary on 9/5----all to evaluate the E/M level for 8/31 only. The most common reasoning explained to me is that this helps the coder/auditor to better the Risk portion of the MDM and/or the overall medical necessity for a given encounter. This auditing style seems to often result in a lower E/M code than what would have been assigned if they had solely considered only the documentation for the specific billed DOS (8/31 only).

I realize there are times when it may be necessary and appropriate to look back at previous encounter notes, such as when trying to determine if a problem is "new" or "established" to the provider, but I'm wondering about the process of doing this routinely when coding/auditing.

Do you have any feedback on whether or not this is appropriate as routine practice and whether or not this is common industry practice? Also, do you know if CMS, CERT, etc., audit physician hospital services in this fashion or if they only audit the individual documentation for the specific billed date of service (i.e., 8/31 notes only)? Thank you!
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Mon Sep 18, 2017 9:45 am

Here’s my take on this.

When a physician performs a subsequent hospital visit, a portion of this service is an “interval history”. To simplify the definition of this, an interval history explains how the patient is responding to the treatment plan put forward upon admission for the conditions identified.

Knowing this, we take it a step further, and look at the CPT definitions of codes 99231 thru 99233:

· CPT code 99231 is a level of service for a patient who has responded positively to the treatment plan, has no new issues and is more than likely very close to discharge;
· CPT code 99232 is a level of service for a patient who is either responding slowly to the treatment plan, or has developed a new, minor problem or a minor complication of treatment. This will more than likely be your most commonly used code; and finally
· CPT code 99233 is a level of service for a patient who is either not responding to the treatment plan, or has developed a new, significant problem or a major complication of treatment.

Built into these levels of service is an instant dichotomy. We are told that the documentation for a single date of service must stand on its own when determining level of service, yet in order to determine the level of service on an individual date of a subsequent hospital visit requires some knowledge of the original treatment plan and condition present upon admission. It is hoped that the physician details this information in the interval history, but oftentimes as an auditor, I find that this section is lacking such detail.

Thankfully, through auditing and education, we have finally gotten to the point where a handwritten note that says “Looks good. Ate breakfast this morning. Will discharge tomorrow” is no longer the gold standard of documentation for subsequent hospital visits. Having said that, knowing that carriers generally pull a single date of service for audit, rather than an entire stay, the documentation for that single subsequent service should include clear documentation of how that patient is responding to the original treatment plan and/or any complications of care or new issues encountered by the patient. Attention to providing a solid interval history can go a long way in helping to define the patient’s progress.

In the end, a medical group’s coding and auditing policy should clearly spell out the method(s) used to determine the level of service in these instances. This can provide a solid footing for eventual appeals of carrier audit determinations for these services if or when the need arises.

Your question has been answered by J. Paul Spencer, CPC, COC
Posts: 45
Joined: Fri Aug 03, 2012 10:22 am

Fri Nov 10, 2017 3:28 pm

Thank you very much for that answer. The significance of those CPT narratives for 99231-99233 seems to be frequently misunderstood or ignored altogether. May I ask for your perspective on a related question? Hypothetical case: patient with cancer is admitted. On day 4 of the hospital stay, the treatment plan remains the same as the day before. Patient's cancer is not expected to improve but also is not technically "worsening". While the overall risk to the patient remains high based on the Table of Risk, does the overall medical necessity for the visit decline for these subsequent visits, as the cancer, although expected to be terminal, is now regarded as a stable condition with no new complications and no changes to the treatment plan? Or does the overall medical necessity likely remain high throughout the admission in consideration of the nature of the disease and its risk to the patient? I realize there is not a clear metric for evaluating medical necessity but would appreciate your input and rationale.

It seems in today's healthcare environment we are trying to keep patients out of the hospital and seek other more cost-effective and less risky alternatives for ongoing patient treatment (such as via home health, etc.) versus continuing to keep the patient in the hospital as an inpatient. As a result, it seems it has become more common for patients to be discharged from the inpatient hospital setting while they are still in the acute stage of illness. Would you agree that this changing climate of healthcare kinda throws a kink into the idea of subsequent visit levels trending downward to low levels right before discharge?

Thank you! Hope you have a great weekend!
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