Wiki Coding Question

[coder21]

How would you code this 99232 or 99233? Thank you


Hospitalist Progress Note (Inpatient Stay)

History: Patient continues to have severe nausea and abd pain, RUQ. Well known history of DM.

Exam: Moderate distress. BP 123/84, HR 88, RR 21

Respiratory: Lungs clear

Cardiovascular: Mild Tachycardia

GI: RUQ Tenderness, steatorrhea

PSYCH: Awake and oriented

NEURO: No tremors

Labs: NA 135, K 4.1, C02 31, BUN 30, creatinine 0.8, glucose 104, HGB 13, HCT 30, PLT 212

Impression:

Chronic Pancreatitis

Type 2 DM

Tachycardia



Plan:

Cont. NPO Status

Cont. IV fluids

Start IV Dilaudid, 1 mg Q 4H, PRN.

 

[thomas7331]

I would code as 99232 - I don't believe the documentation supports high level MDM.

 

[coder21]

Thank you. I was told high because the person count 4 points in the Number of dx and High table for risk for the parenteral controlled substance. I don't see this.