- Indicate status of all problems in the plan of care; identify them as stable, worsening, exacerbating (mild or severe), etc.;
- Document all diagnostic procedures being considered;
- Identify surgical risk factors involving co-morbid conditions, when appropriate; and
- Associate the labs ordered to monitor for toxicity with the corresponding. medication (e.g., “Continue coumadin, monitor PT/INR”). A patient maintains the same level of risk for a given medication whether the dosage is increased, decreased, or continued without change.
Determine Complexity
To determine the final complexity of medical decision making, two of three categories must be met. For example, if a physician satisfies the requirements for “multiple” diagnoses/treatment options, “minimal” data, and “high” risk, the physician achieves moderate complexity decision-making.
Remember that decision-making is just one of three components of evaluation and management services, along with history and exam.
Determining the final visit level (e.g., 9922x) depends upon each of these three key components for initial hospital care and consultations, and two key components for subsequent hospital care. However, medical decision making always should drive visit level selection as it is the best representation of medical necessity for the service involved.
Contributory Factors
In addition to the three categories of medical decision making, a payer (e.g., TrailblazerHealth) may consider contributory factors when determining patient complexity and selecting visit levels.
For example, the nature of the presenting problem may play a role when reviewing claims for subsequent hospital care codes (99231-99233). Found in the code descriptors of the CPT manual, problems are identified as:
- 99231: Stable, recovering or improving;
- 99232: Responding inadequately to therapy or developed a minor complication; and
- 99233: Unstable or has developed a significant complication or a significant new problem.
Although this is not a general requirement, it represents a locally established standard for reviewing claims for medical necessity. It should not be used exclusively to determine the visit level.
Be sure to query your payer’s policy via written communication or Web site posting (e.g., www.trailblazerhealth.com/Publications/Job%20Aid/medical%20necessity.pdf) for guidance on how payers review documentation. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.