Wiki 99232 vs 99231

[KaylaRieken]

If a patient has multiple diagnoses but is stable, what is the correct code to be using?

I have a patient that is in the hospital for over a month now. He has a renal laceration, gross hematuria, acute kidney injury, bladder clot retention, acute blood loss anemia, and more dx not urology related. Doctor dictates what could be a 99232 everytime. If the patient is stable, is that ok to give that level everytime?

 

[kellz0913]

I believe that if the patient is stable then it should be coded as a 99231. Especially if he isn't doing anything new to the patient.

 

[KaylaRieken]

Ok, that's what I thought too. Thanks for reminding me. I was second guessing myself.

 

[Kris Cummings]

Remind your doctor the differences between 99231 and 99232. Where 99231 CPT reads, the patient is usually stable, recovering, or improving and 99232 reads, the patient is usually responding inadequately to therapy or has developed a minor complication. There's also a time-component for both services, in case this patient is requiring your doctor unit/floor time devoted strictly to him; 99231 is typically 15 minutes between bedside and unit/floor time, and 99232 is typically 25 minutes. If time should be the controlling factor, your doctor should document individual patient context of counseling and/or coordination of care as well as the time component, i.e., spent ___ mins of this ___ min appt as described (above, in HPI, in A/P, etc.). Hope this helps.