Wiki 99231 vs 99232

[KaylaRieken]

At your practice do you see yourself billing more 99232s than 99231s? I know the guidelines to the E/M codes but our doctors over dictate the HPI and Exam everytime. For medical decision making if they have numerous problems, (lets say urinary retention, acute-on chronic kidney disease, chronic right ureteral stricture with hydro, uti, and radiation-induced cystitis) and they are stable everyday for 4 days, would this be 99232 or 99231 every day? I think I confuse myself with the rule of thumb being stable/improving or responding inadequately/minor complication.

 

[SharonCollachi]

We pretty much go with stable/not needing much is 99231, not improving/having some issues is 99232, and unstable/needing a whole lotta things is 99233.

For instance, stable but has developed opioid-induced constipation. That's a very minor issue, there is a constipation protocol that is put into place, still a 99231.