Bring documentation improvement into the office setting
Look out for these superbill deficiencies
by Robert S. Gold, MD
So far, my columns have aimed at the acute-care setting and how understanding of diseases and code assignment affect the hospitalized patient. What’s been missing is the physician office setting and the impact, now and in the future, of severity of illness and proper ICD-9 code assignment.
We’ve heard about pay-for-performance and some of us have been involved with severity of illness issues in the physician’s office. We might have also seen physicians’ superbills—the pieces of paper they might carry around in the hospital that they use to circle codes they intend to use for hospital visits and to which they attach a CPT code for professional billing (i.e., evaluation and management [E/M] codes).
Grab one of these pieces of paper from one of your physicians some time. Look at it carefully from his or her perspective. What you will often see are codes for the office that he or she tries to use for his hospital visits (e.g., chronic, stable diseases)—which are the wrong codes.
I’ve seen 250 on more than one physician superbill, and, frequently, 250.00, regardless of the lack of control or the involvement of other organs. I’ve seen 401.9 for all hypertensions, regardless of urgency and the involvement of the kidneys. I’ve seen 496 in the hospital with an unstable patient—when 491.21 would be appropriate—and in the office when the patient is stable. I’ve seen 436 for strokes and for follow up after strokes.
The physicians don’t know that this is a problem. Whether they have a good coding professional in the office or not, they often need help and direction. Let’s look at a couple of scenarios.
Heart failure
In the hospital, heart failure can be a chronic, stable condition or it can be acute—or acute on top of chronic. In the office, it is mostly chronic, or it was acute in the hospital and is totally over now with no residual whatsoever. Regardless of the circumstances, 428.0 is inadequate. However, that’s often the only heart failure code you’ll find on internal medicine, family practice, and cardiology superbills. Examine a few for yourself.
Acute heart failure in the hospital setting carries a much higher severity of illness when the physician identifies it as right heart failure or left heart failure. Acute left ventricular systolic failure (428.21) carries a higher severity of illness than acute left ventricular diastolic failure (428.31). Also, acute heart failures have a cause, and it’s important for the physician to document this (e.g., noncompliance with medications, volume overload, acute ischemia [unstable angina or non-ST segment elevation myocardial infarction], or hypertensive crisis). These all increase the complexity of medical decision-making aspect of the physician’s E/M code.
When the physician gets back to the office setting, he or she will be seeing the patient not for 428.0, but for chronic systolic failure in a patient with an ejection fraction (EF) under 40% (428.22), or for chronic left ventricular diastolic failure with a sustained ejection fraction (428.32).
Each of these also has a cause (e.g., ischemic heart disease, hypertensive heart disease [with or without chronic kidney disease], valvular heart disease, or toxic cardiomyopathy). All of these increase both the severity of illness for the visit and the complexity of the medical decision-making for E/M billing. But when all you see is 428.0, it’s not worth much at all.
Once in a while, the physician might identify that the patient has decompensated and is in acute heart failure, requiring either treatment in the office or hospitalization. In this case, the physician deserves a higher level of acuity, but all you typically see is 428.0.
Diabetes
Here is another instance when the superbill contains one valid or invalid code—250.00 or 250—regardless of the complexity of the patient’s diabetes. There is rarely any fourth-digit precision and, certainly, no fifth-digit severity with these as the only choices.
First, 250.xx codes do not adequately describe all diabetes. When it is diabetes secondary to the fifty other causes (e.g., postpancreatitis, chronic steroid use, or congenital or other genetic disorders), there’s no way to depict what’s wrong with the patient if all the physician has is in the 250 range.
Severity of illness for diabetic patients depends on identifying neuropathies, retinopathies, nephropathies, and the other -opathies. When dealing with nephropathies, it’s also important to clarify the severity of the renal involvement with the code for the stage of chronic kidney disease. When the patient has a diabetic ulcer and all that appears is a 707 code for ulcer, I don’t know where it is or what caused it.
Stroke
Here’s another situation in which the inpatient and outpatient coding rules are different and all you usually see is 436 on the superbill. The physician is probably using that code in the hospital as well as in the office after the hospitalization for the stroke.
Unfortunately, the code isn’t appropriate for either scenario. Whether the 433 series or the 434 is appropriate in the hospital, neither is appropriate back in the office after the stroke. Instead, the physician should use the code for a history of stroke and the appropriate codes for all of the residuals of the stroke, including whether the residual hemiplegia (if there is residual hemiplegia) involves the patient’s dominant or nondominant side. The more conditions that the physician is following in the office, the more post-stroke therapies the patient can receive.
The acute stroke codes are proper in the office setting only when the physician diagnoses the stroke in the office. In these cases, select the appropriate fourth digit and use a fifth digit of one.
Chronic respiratory failure
Most physicians, even pulmonologists, don’t have chronic respiratory failure on their superbills—for inpatient or outpatient use. They have the codes for stable chronic obstructive pulmonary disease, stable asthma, and cystic fibrosis. These patients may not have chronic respiratory failure, but when they do, they are very ill. When it is appropriate to use the terminology and the 518.83 code, the physician should do so—both in the hospital, where it may be acute on chronic respiratory failure, and in the office, where the patient is being followed for chronic respiratory failure due to whatever the cause is.
The patient must meet the definition for this documentation. For example, the codes are valid if the physician finds the patient with an approximately normal pH (7.4) and pCO2 chronically greater than 55, hypoxemia at a level that would be fatal without supportive therapy, or a pCO2 greater than 35.
Get together with your physicians and give them a hand in these cases. They’ll appreciate it and may turn around and help you.