help with code

[Pai5ley]

This is all the documentation I have. Can I use 99231?


Patient seen today
with history of DM, obesity
admitted with possible cva
CT head also shows possible acute infarct
He is feeling better
Waiting for MRI and carotid dopplers, will continue to follow.

 

[mitchellde]

There is no chief complaint. Possible CVA will not pass as a chief complaint, you have no exam. You have really no visit level that I can see. Without the chief complaint there is no level of history that can be counted. Also you only have one element of MDM which is risk, I do not see diagnosis/management option or complexity. I say this is an encounter note that cannot be coded.