Help with 99231 or 99232?

ladybird

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Bay City, Michigan
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My Endo Dr. gives me the following for a hospital subsequent visit and he is billing for a 99232. I am waivering on either a 99231 or no billing, due to no exam, can't tell if he saw the patient? Can anyone offer their advice?

Progress note - Endocrine consult request per DR._______ regarding apparent hypoglycemia of ? Etiology in a 25 yo female patient with recent recurrent seizures and blood glucose from available records of 68 mg/dl. Blood glucose levels since admission 89 - 116 mg/dl. No current signs of sepsis, chronic adrenal insufficiency, hypothalamic-pituitary disorder, underlying neoplasm, or unusual drug related hypoglycemia or increased alcohol intake. Recent blood glucose levels noon = 107, pm = 115, hs = 115, am = 116 and noon = 103 mg/l. Normal serum cortisol 15.8 and sed rate = 7. Currently on D5W in NS 75 cc/hr with blood glucose levels pm = 114 and am = 133 mg/dl. Have started tapering down the IV dextrose to 50cc/hr to determine if this is sustained vs transient hypoglycemia. Resulting blood glucose levels hs = 115 and am= 90 mg/dl. Will continue to monitor on IV dextrose 25 cc/hr.
 

dwaldman

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99232 for medical decision making requires 2 of the 3: three problem points, Data reviewed 3 points and moderate risk. The diagnoses the physician provided look like they are within the history: 251.2 hypoglycemia and 780.39 recurrent seizures. There is a review of systems (2-9) and the history would meet EPF history. He does specifically state hypoglycemia, uncontrolled for an established problem worsening for 2 points with additional point for recurrent seizures. But the lab values he describes are probably relying the answer to whether it is improving, worsening, or uncontrolled. The data reviewed I didn't know if this was just lab reviewed 1 point or second interpretation 2 points. Regarding the risk, I saw IV fluids w/ additives might meet what he is describing. You could review with the physician for future encounters about the need for documentation of the exam that was performed with possibly an impression or diagnosis section with indication of the status of those conditions. I have also seen a subsequent IP encounters documented that does not follow a format as close as it should to meet the level suggested.
 
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