Neurology & Pain Management Coding Alert

Question: I have physician documentation stating that an inpatient "continues to have left retro-orbital headache; has decreased to 5/10 with intramuscular triptan." The provider performed a problem focused exam and moderate complexity medical decision making. Should this subsequent hospital care be reported with 99231 or 99232? Florida Subscriber Answer: Use code 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit) in this instance. The scenario described includes [...]