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Wiki General Surgery Rounds

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baroquecoder

baroquecoder

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West Point, CA
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Chief complaint: GS
HPI:0
ROS: 0
Subjective: Urine input/output, o2 sats, BP
Exam: Const, Lymph, Resp, MSK, Skin, cardio, Neuro

Assessment plan: sepsis, diabetes, ARF, AKI, intestinal obstruction, dehydration, hypokalemia

Surgeon performing rounds on a patient, is this acceptable as 99233?

Is it always necessary to have a chief complaint and an HPI for the inpatient E/Ms ?
 
Hello baroquecoder,

Yes, a provider should have documented the CC and HPI on their inpatient records. Since this is a Subsequent inpatient visit you would need 2/3 key components supported. The provider documentation definitely does not support 99233 and should not be excepted as they can't simply list organ systems and list diagnosis and not describe their findings or what their A/P is.



M.Hannus, CPC, CPMA, CRC
 
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