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Home / Cardiology Coding Center / 99233 CPT Code, Level 3 Hospital Followup Note –Dummies Guide 2017-2018

99233 CPT Code, Level 3 Hospital Followup Note –Dummies Guide 2017-2018

99233 CPT code 7 high risk

99233 CPT code 7 high risk

A 99233 CPT code explanation, 99223 examples, 99233 example note, 99233 RVU amount, 99233 wRVU / work RVU amount and a 99233 template for EMR.

What is CPT Code 99233?

CPT code 99233 is assigned to a level 3 hospital subsequent care (follow up) note. 99233 is the highest level of non-critical care daily progress note. When it comes to 99233 documentation is critical, however understanding of the documentation required is even more critical. WorK RVU (wRVU) for cpt code 99233 is of course higher than that for 99232.

How many work RVU (wRVU) are given for a 99233?

A 99233 CPT code is associated with 2.0 work RVU’s also known as wRVU.

A 99223 = 2 wRVU

In general when is a 99223 code appropriate?

When it comes to coding, documentation is key and you would be surprised to see just how little writing is required to ensure all the key criteria. My personal rule however is that common sense should prevail as opposed to trying to game a system with documentation.

If a patient is improving or remains stable CPT code 99233 is probably not appropriate. Many times, rounds are made on patients where it is essentially a continue meds, continue monitoring, improving basis, essentially a courtesy visit. These are not meant to be 99233’s.

Often, for example the day after a patient is admitted, many management decisions continue to evolve and treatment changes are made. For example blood pressure control or heart failure would require specific medication adjustment and tests that need to be reviewed. Development of renal failure for example that would require holding meds, getting tests, following them and potentially arranging consultation and discussing with specialists. This would be a classic 99233 CPT code type situation. In general, as the patient improves to a state where they are improved and awaiting final stabilization for discharge, CPT code 99232 rather than 99233 would be appropriate.

99233 CPT code 1 basic

Example of hospital days where CPT code 99233 may be appropriate as long as the documentation is correct

Admission – Patient with shortness of breath and chest pain, comorbidities present, diagnosed with congestive heart failure and known ischemic cardiomyopathy treated medically, IV meds given, complexity is high.

CPT code 99223

Day 2 – Patient improved, meds changed to PO, home meds restarted, no invasive tests planned, continuing to monitor.

CPT code 99232

Day 3 – Kidney function worsens, meds held and changed appropriately, concern for cardiac output being low, nephrology consulted, situation worsened from prior day.

CPT code 99233

 Day 4 – Echo reviewed, cardiac function worse than thought, thinking about right heart cath, dobutamine started on floor, IV diuresis ongoing, discussed with consultants.

CPT code 99233

Day 4 – Situation improves, renal function stabilizes with inotropic support and renal recommendations, breathing improved, meds regimen stable, labs and CXR stable, patient likely to be discharged in next few days.

CPT code 99232

Documentation is critical when it comes to a 99233

Since 99233 is higher levels of billing when it comes to inpatient follow up, it is likely to come under more scrutiny and therefore documentation and understanding of requirements is critical. In general, many inpatients are truly sick and if there is genuinely high complexity in terms of the patient and the situation the documentation will take care of it by itself. When we take a deeper dive in to the guidelines for documentation it becomes ridiculously convoluted and takes an investment of time to truly develop an understanding to where it can be applied. Once that understanding is developed the whole thing becomes much easier. Unfortunately a note becomes like a point system where a certain number of points are required for a certain number of categories. That can be advantageous however when it comes to efficiency in documentation for those that understand how it works.

The key Components of a 99233

 To bill a 99233 you need at least 2 of the 3 key components.

Detailed interval history

Detailed examination

High complexity decision making

See below for a more detailed breakdown of these categories

Typically one would also:

Coordinating care with other providers

Counseling patient and family

Alternatively a 99233 can be billed on the basis of time as described below.

Time based 99233

The 99233 represent what would typically be 35 minutes of care at the patient bedside or on the patient’s floor or unit.

If 35 minutes was spent with a patient, if there is specific documentation, it is felt that the time alone may justify the 99233. That documentation must include 1) Total time spent (>35mins) 2) Description of the counseling and care coordination 3) State that over half the time was spent on counseling and coordinating specifics of care.

99233 CPT code 2 history

Detailed interval history

4 HPI elements (locations/severity/duration/associated symptoms etc.) or the status of 3 chronic problems

99233 Examples of interval history:

Chest pain (1) exacerbated last night, left chest (2), radiates to neck (3), sharp (4) and intermittent in nature (5), associated shortness of breath (6).

Shortness of breath (1) noted last night, intermittent (2) and occurring at rest, no relation to exertion (3), no chest pain (4), no nausea (5) or diaphoresis (6).

These examples contain more than the 4 elements required for the HPI element of the 99233. If a patient has a worsening of a condition and it is described appropriately then this should be easily fulfilled.

Note that if there isn’t a 4 point interval HPI, documentation of the status of 3 chronic medical conditions and 2 review of systems are reportedly acceptable surrogates for this in a 99233.

99233 CPT code 3 exam

Detailed examination

12 bullet points from any organ system

Also described as 6 areas with 2 bullets each, or 2+ areas with 12 total bullets

1 point includes 3 vital signs reviewed

1 point for general appearance

1 point each for Neck / lung / heart / carotids / abdomen / liver / edema / digits / skin / mental status / neuro etc.

In general I would say include 6 organ systems regardless.

99233 examples of detailed exam:

In this cardiac strong exam we have 9 different ‘systems’ which fulfills the 6 suggested, we have 15 bullets, this exceeds the required 12.

1 point for these 3 vital signs

BP 127/84, HR 75, 02sat 96% on air (1 point for the 3 vitals)

1 point for this general exam

Laying in bed, mild increase work of breathing

1 point for this mental status exam

Alert and oriented, can follow instruction

5 points for this cardiovascular exam

Regular rhythm, soft systolic murmur, no added sounds (auscultation of heart)

Forceful apical beat (palpation of the heart)

Normal carotid upstrokes (palpation of carotid)

2+ femoral and radial pulses (examination of peripheral arteries)

1+ bilateral pitting edema (exam of periphery cardiovascular)

1 point for this musculoskeletal exam

No cyanosis or clubbing noted in the digits

1 point for this exam of neck

JVP 10cm, elevated, bed at 45 degrees

2 points for this respiratory exam

Lungs clear to auscultation bilaterally

Respiratory effort mildly increased

2 points for this abdominal exam

Soft and non tender, No masses felt

Auscultation normal bowel sounds

1 point for skin

No new rashes or ulceration noted

 

High complexity decision making – For a 99233, documentation needs to include at least 2 out of 3 of the following

Extensive management options for diagnosis / treatment

Extensive data to be reviewed

Labs / Radiology tests / PT/OT notes / Consultants notes / Tests to be ordered documented

High risk of complications or comorbidity

Comorbidity documentation that pertains to presenting issues

Risks associated with tests ordered or performed

Risks associated with management issues

For a 99233 typically a combination (2 out of 3 needed) of 4 problem points, 4 data points, and documentation of high risk.

99233 CPT code 5 problem points

99233 high complexity decision making – 4 problem points 

Minor problem points (maximum of 2) = 1 point

Established problem that is stable or demonstrates improvement =1 point

Established problem that worsens = 2 points

New problem with no further work up planned (max of 1) = 3 points

New problem, with additional work-up needed =4 points

99233 CPT code 6 data points

99233 high complexity decision making – 4 Data Points

Review or order labs =1 point

Review or order imaging =1 point

Discuss test with performing physician =1 point

Independently review image / tracing / specimen =2 points

Decide to obtain old records =1 point

Review and summarize old records =2 points

99233 CPT code 7 high risk

99233 high complexity decision making -Demonstration of High Risk

Needs one of the following 3 elements

Presenting problems

Diagnostic procedures

Management options

Presenting problems

One or more chronic illness with exacerbation or progression

Acute or chronic illness posing a threat to life or organ system (resp distress / pulmonary embolism / myocardial infarction / acute kidney injury etc..)

Diagnostic procedures

Contrasted cardiac studies

Endoscopy

EP studies

Management options

Elective or emergency major surgery

IV controlled therapy

Drug therapy requiring monitoring for toxicity

DNR or establishment of supportive care only

Comprehensive templates for 99233

Here is a comprehensive template for a 99233. I’m sure people will argue that its overkill and takes a lot of time, however I disagree. If these elements are reviewed it clearly improves patient care as multiple pertinent and often ignored elements will be reviewed and taken in to account and can influence decision making. The documentation is comprehensive and in reality not overly time consuming in the era of EMR, particularly if auto-population is used and you are familiar with the patient. If a significant portion of these elements is followed you will much more than fulfill the documentation criteria for a 99233. For those learning the specifics of documentation I would suggest starting comprehensive like this then when you feel comfortable the note can be trimmed significantly and tailored to needs.

Interval HPI;

(If new issue has arisen then state here and if possible describe with 4 points and associated symptoms)

Lab review;

(Pull in lab values if desired)

(Comment on any changes on the review)

Test Review;

(Pull in radiology testing) New radiology tests include

(CXR reading and review) CXR was reviewed and demonstrated

(EKG 12 lead reading and review) 12 lead EKG was reviewed and demonstrated

(Telemetry review and comment) Telemetry was reviewed and demonstrated

Meds;

(Pull in meds if required)

Physical Exam;

(Pull in BP, HR, temp, 02sat)

(Laying in bed / sitting in chair / ambulating)

(Comfortable / uncomfortable / other comment)

(Alert and oriented, able to answer questions)

(JVP is not elevated, carotid exam normal)

(Regular rate and rhythm, no murmurs noted, no added heart sounds, normal apical pulsation)

(2+ radial pulses bilateral, 2+ femoral/tibial pulses bilaterally)

(no edema in the lower extremities)

(no clubbing or cyanosis)

(Lungs clear to auscultation bilaterally, respiratory effort normal)

(Abdomen soft and non tender, normal bowel sounds)

(No new rashes or ulceration noted)

Problems

(Problem list being actively managed)

(Significant new problems interval – work up ordered, treatment started)

(Problem 1 – stable / treating, – management)

(Problem 2 – stable / treating, – management)

(Problem 3 – stable / treating, – management)

(Problem 4 – stable / treating, – management)

Specifics to the 99233

(Discussion with other consultants)

(Discussion with patient and family)

(Review of other notes)

(Obtain old records / summarize old records)

(New studies ordered)

(Code status review)

(IV controlled therapy)

(Drugs being monitored for toxicity)

Comprehensive cardiology centered template example for 99233 – see below for a detailed breakdown and discussion

Interval HPI;

Shortness of breath worsened overnight, caused to wake from sleep, worse with exertion and lying flat, no further chest pain, no nausea or diaphoresis.

Lab review; 

Labs reviewed

BNP is elevated

Cr increased from 1.1 to 1.6

Troponin trend 0.11 to 0.13

ABG showed some hypoxemia

Test Review;

CXR was reviewed and demonstrated findings consistent with worsening of pulmonary edema

12 lead EKG was reviewed and demonstrated sinus rhythm at a rate of 90

Telemetry was reviewed and demonstrated sinus rhythm rate 80-110

Meds; 

Medication list or can simply say was reviewed

Physical Exam;

BP 100/70, HR 90, temp 98.0, 92% 02sat on 4 liters

Alert and oriented and able to answer questions

Laying in bed

Mildly increased work of breathing

JVP elevated to 10cm at 45degrees, carotid upstroke normal

Cardiac exam, irregular rhythm, no murmurs noted, no added heart sounds, normal apical pulsation

2+ radial pulses bilateral, 2+ femoral bilaterally

1+ bilateral pitting edema in the lower extremities

No clubbing or cyanosis

Lungs have mild creps at bases bilaterally, respiratory effort normal

Abdomen soft and non tender, normal bowel sounds

No new rashes or ulceration noted

Problems 

NSTEMI, s/p PCI

Atrial fibrillation, chronic

Hypertension, chronic, controlled

Diabetes Mellitus, controlled

CHF, acute on chronic systolic

AKI on likely CKD

Interval new issues

CHF / AKI – Interval development of respiratory distress and acute kidney injury. Likely congestive heart failure exacerbation, will order echocardiogram to assess LV function, intravenous Lasix administered, will hold ACE inhibitor in the setting of AKI, continue other meds as stated, monitor renal function closely

Ongoing Issues

NSTEMI / CAD – s/p PCI to RCA 4 days ago, continue aspirin and Plavix, continue BB, holding ACE due to AKI, checking echocardiogram to assess LV function

Hypertension – currently normotensive, holding ACE, continue other meds listed

Atrial fibrillation – rate controlled, continue beta blocker, continue Coumadin for anticoagulation, INR is 1.8 aiming for 2.0-2.5. Will discuss with pharmacy.

Specifics to the 99233

Discussed with general medicine team

Discussed with patient who understands issues and daughter at bedside

General medicine note reviewed

Old echo reviewed, EF was 55%, repeat pending

New echocardiogram ordered

Remains Full Code

No IV controlled therapy started

Monitoring Coumadin with INR, co-managing with pharmacy

Detailed Breakdown of the 99233 note template and example.

The example above is a relatively extensive documentation, it would take some people a long time to do that and others could run through it relatively quickly. In my opinion, if there is truly a higher level of care such as a 99233, the time and documentation should reflect that. It can, if methodically done, be in an efficient manner.

By no means is all the documentation above needed. The note basically scores top points in every requirement, and remember only 2 out of the 3 are needed.

Interval HPI

Shortness of breath worsened overnight, caused to wake from sleep, worse with exertion and lying flat, no further chest pain, no nausea or diaphoresis.

This has already hit over the 4 points required. Theoretically only 1 of the other 2 categories (physical exam and complex decision making) is now needed.

Note that if there isn’t a 4 point interval HPI, documentation of the status of 3 chronic medical conditions and 2 review of systems are acceptable surrogates.

Lab review;

Labs reviewed

BNP is elevated

Cr increased from 1.1 to 1.6

Troponin trend 0.11 to 0.13

ABG showed some hypoxemia

The review of the labs contribute a point to the data point section of the medical decision making section. Remember, 4 data points are needed. Also the increase in creatinine supports the AKI as a new critical diagnosis, the BNP supports CHF acute exacerbation and the hypoxemia supports respiratory distress. Remember, a new significant problem with additional work up planned fulfills 4 points and already qualifies for high risk.

Test Review;

CXR was reviewed and demonstrated findings consistent with worsening of pulmonary edema

12 lead EKG was reviewed and demonstrated sinus rhythm at a rate of 90

Telemetry was reviewed and demonstrated sinus rhythm rate 80-110

Personally reviewing the radiology test CXR is 2 point. Independent review of the EKG is 2 points (If we had decided to review old records and summarized that would have been 2 points). Later we order an echo, that’s a further point. We had already reviewed the lab above, that’s a further point. In total here we have 6 data points that exceeds the 4 data points required for the 99233. That’s already one of the 2 requirements of the complex medical decision making out the way. Remember it has to be 2 out of the 3 of 4 problem points, 4 data points and high risk. We already have evidence for the new significant diagnosis / problem point above so in theory this note already qualifies for a 99233.

Physical Exam;

BP 100/70, HR 90, temp 98.0, 92% 02sat on 4 liters (1 point)

Alert and oriented and able to answer questions (1 point)

Laying in bed (1 point)

Mildly increased work of breathing in general (1 point)

JVP elevated to 10cm at 45degrees, carotid upstroke normal (1 point)

Cardiac exam, irregular rhythm, no murmurs noted, no added heart sounds, normal apical pulsation (2 points)

2+ radial pulses bilateral, 2+ femoral bilaterally (1 point)

1+ bilateral pitting edema in the lower extremities (1 point)

No clubbing or cyanosis (1 point)

Lungs have mild creps at bases bilaterally, respiratory effort normal (1 point)

Abdomen soft and non tender, normal bowel sounds (2 points)

No new rashes or ulceration noted (1 point)

Remember that a total of 12 bullets are needed. Ideally 6 organ systems at least. Can be 12 bullets from at least 2 technically. 3 vital signs are 1 point and general appearance is 1 point. In the exam above we have a total of 14 points, we have 6 organ systems, it easily fulfills requirements.

Problems 

NSTEMI, s/p PCI (established problem, stable 1 point)

Atrial fibrillation, chronic (established problem, stable, 1 point)

Hypertension, chronic, controlled (established problem, stable, 1 point)

Diabetes Mellitus, controlled (established problem, stable, 1 point)

These 4 stable points are ok as they are issues that significantly impact treatment.

CHF, acute on chronic systolic (established problem, worsening (2 points) vs. new problem significantly threatening issue with further work up planned (4 points)

AKI on likely CKD (new problem, significantly threatening issues, further work up planned (4 points).

Once again, our documentation here is basically worth 12 problem points, remember we only need 4; the acute CHF or the AKI would alone have been enough to suffice.

Interval new issues

CHF / AKI – Interval development of respiratory distress and acute kidney injury. Likely congestive heart failure exacerbation, will order echocardiogram to assess LV function, intravenous Lasix administered, will hold ACE inhibitor in the setting of AKI, continue other meds as stated, monitor renal function closely

 Ongoing Issues

NSTEMI / CAD – s/p PCI to RCA 4 days ago, continue aspirin and Plavix, continue BB, holding ACE due to AKI, checking echocardiogram to assess LV function

Hypertension – currently normotensive, holding ACE, continue other meds listed

Atrial fibrillation – rate controlled, continue beta blocker, continue Coumadin for anticoagulation, INR is 1.8 aiming for 2.0-2.5. Will discuss with pharmacy.

In the section above we have simply bolstered our documentation above. We have laid out the problems that are new and significantly threatening and demonstrated the further work up planned. We have reported the management of the chronic issues. We have documented tests planned and discussions had.

Specifics to the 99233

Discussed with general medicine team

Discussed with patient who understands issues and daughter at bedside

General medicine and PT note reviewed

Old echo reviewed, EF was 55%, repeat pending

New echocardiogram ordered

Remains Full Code

No IV controlled therapy started

Monitoring Coumadin with INR, co-managing with pharmacy

The discussion with the other physicians involved and also the discussion with the family is a supporting factor for complexity. The review of the medical and the PT notes can act as a point in data. The old echo review can act as a point in data.

The ordering of the new echo acts as a data point also. If this had been a CT angiogram, cath, or other contrasted cardiac scan, or endoscopy for example, it would have actually fulfilled the entire criteria for high risk. If there was IV parenteral therapy, i.e IV pain meds that are controlled, then that also would have acted as high risk. The INR monitoring for the Coumadin, given its significantly high risk for toxicity and need for monitoring can act as a high risk feature also.

Brief note example that fulfills the criteria for a 99233

I’m not a fan of minimalist notes, I think it can breed complacency and doesn’t help with the thought process. The following shows however that when sticking to the criteria for a 99233 we can still achieve what we need to with a minimal note.

Interval history

Shortness of breath worsened overnight, PND, worse with exertion and lying flat, no chest pain, nausea or diaphoresis.

4 interval HPI points satisfied with a worsening shown

Objective points

BP 100/70, HR 90, temp 98.0, 92% 02sat on 4 liters

Alert and oriented, anxious, mildly increased WOB, JVP 10cm, carotid normal, irregular rhythm, no heart murmurs noted, normal apical pulsation, 2+ femoral bilaterally, 1+ bilateral pitting edema in the lower extremities, No clubbing or cyanosis, lungs have mild creps at bases bilaterally, respiratory effort normal

Abdomen soft and non tender, normal bowel sounds No new rashes or ulceration noted

Theoretically we could stop here, we have 2 of the 3 main sections with all criteria fulfilled, interval HPI has 4 points and the physical exam has 12 bullets with 6 systems. This highlights how knowledge of what’s required can allow focus on main issues if that is the aim. In reality the note will continue thought. 

Assessement

New respiratory distress, CHF acute exacerbation

Acute Kidney injury

INR is 1.8, patient on coumadin

Both of the above are 4 points each, just one of them would suffice for the medical decision making high complexity requirement. The INR and Coumadin and need for monitoring demonstrate a high risk. In theory this is all that’s needed, you could even take out the physical exam section and still have fulfilled 2/3 requirements as needed. 

Plan

IV diuresis, repeat echocardiogram, stop ACE inhibitor, monitor renal function

This note was very short, but still way over the requirement in terms of points needed, essentially its point system dense and easily fulfills the documentation needs for a 99233.

Even briefer note example that fulfills the criteria for a 99233

Interval history

Shortness of breath worsened overnight, PND, worse with exertion and lying flat, no chest pain, nausea or diaphoresis.

4 interval HPI points satisfied with a worsening shown

Objective points

Technically the exam isn’t required

4 data points can be; EKG reviewed no significant ST-T changes (2 points). CXR discussed with radiology concern for pulmonary edema (1 point). Creatinine elevated to 1.6 (1 point). INR is 1.7 on Coumadin, will discuss with pharmacy regarding dose and monitoring (this is monitoring of a high risk drug and fulfills the criteria for high risk)

4 data points already and high risk demonstration, theoretically the note can stop here and the 99233 criteria have been fulfilled, we have 2 out of the 3 needed, we skipped the exam here remember. 

Plan

IV diuresis, hold ACE, order echo, monitor renal function

This note was very very short, but still met the requirement in terms of points needed, essentially its highly point system based and despite the brevity of the note fulfills the documentation needs for a 99233.

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