Wiki Inpatient coding level for subsequent visit

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wynonna

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Hinsdale, MA
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Patient is in for epistaxis and has history of ETOH abuse. No other issues and no comorbidities.
MD does detailed history.
MD does detailed exam.
MDM is low.
What would be the level for a subsequent visit?
thank you
 
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As subsequent 99231-99233 require 2 of 3, detailed hx and detailed exam lead to 99233.
That being said, some employers (and some carriers) have the requirement that MDM MUST be 1 of the 2. If that is the case, MDM low is 99231, so you would not be able to code above that.
The theory of requiring MDM is for the overarching medical necessity. For example, if it's a resolved nose bleed and history of ETOH abuse but sober for the past 15 years, why was a detailed history and detailed exam needed?
My personal opinion (and my employer's policy of requiring MDM) would be 99231.
 
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I've been told any 2 out of 3 counts. But this doesn't sound right when patient is just being treated for epistaxis. He has daily ETOH use. I still can't see a 99233 in this scenario, but the CPT guidelines for any 2 of 3 mean detailed History and Detailed Exam are 99233.
Are there any sources which clarify this out there?
 
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What you are describing is that overarching criteria of medical necessity. That is a very gray area and hard to pin down. I agree that 99233 seems overcoding for a stable patient with nosebleed. However, coders aren't trained clinical professionals and I do my best not to step on toes and question clinical decisions unless it is very cut and dried. This type of situation is exactly what led to the 2021 outpatient E/M changes.
If it's a patient with daily ETOH abuse (not just 1 glass of wine with dinner every night), it's possible there were additional complications from that and then 99233 is more palatable to me.
If your employer and the carrier do not require MDM to be one of the elements, I would likely code 99232 unless the note documents some complications or additional medical necessity, and would then consider 99233.
 
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