Pulmonology Coding Alert

Question: The distinction between the documentation requirements for 99231 (subsequent hospital care, per day, for the evaluation and management of a patient which requires two of three components) and 99232 (subsequent hospital care, per day, for the evaluation and management of a patient, which requires two of three components) is not very clear. Must new orders accompany 99232? In auditing hospital service, it would be very helpful to have a work list of the things that must be in a note to justify the 99232 level. Michael Haynes University Medical Associates, Augusta, Ga. Answer: There are several distinctions between the 99231 and 99232 subsequent hospital care codes. The history and examination portion for 99232 are expanded problem focused as compared to the 99231, which is only problem focused. The main issue is the medical decision-making, which is moderate for the 99232 and only straightforward-to-low for the 99231. Review of Appendix DClinical Examples of CPT 2000 sheds a little more light on patients in the 99232 category. These patients are responding inadequately to treatment or have a new problem that needs to be treated. This means the physician treats the patient with a variety of options. There are new tests, procedures, drug administration and plans. Should there be new orders? Yes. Because the patient is not responding to present treatment properly or has a new problem, which will need treatment, you should see new orders for the tests, procedures, etc.