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#1
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Hospital subsequent note--no CC stated. I'm going back and forth with a co-worker between a 99231 and 99232. Your insite would be appreciated.
Afebrile, on room air, no resp distress, no CP, no dyspnea, no hemoptysis, hemodynamically stable, no vomiting. G-tube feeds held last night. VS-36.9, 68, 24 98% PE: sleeping comfortably, HEENT-no nasal flaring, MMM, chest-few crackles at base of right lung, Heart-RRR, ABd +BS, Ext WWP, no cyanosis, + clubbing A: 20 y/o with CF pulm exacerbation, PI Plan-Continue Timentin, Amakacin IV Aggresive Pulm toilet Monitor glucose PFT's today |
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#2
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Based on this note I would go with a 99232. Even though the MDM was only straightforward you only need two of the three for these visits. I got EPF for the history and EPF(97) or detailed(95) for the exam. I'd be interested to see what others get.
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#3
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I'm leaning more towards a 99232 as well (according to 1995 guidelines).
__________________
Carrie, BS, CPC |
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#4
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I would also based on the guidelines go with 99232.
__________________
Kelly Long CPC, CFE Claims Auditor Senior Fraud Investigator |
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#5
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I agree 99232 - based on exam (EPF) and medical decision making. (moderate)
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