Wiki inpatient level of service

[kls1027]

Is a code of 99332 automatically assigned when the provider states that one of the symptoms is improving? The documentation supports 99233 with all three sections of the E/M. The patient is on an IV, has parental drugs, a consult is requested from a specialty dept to determine continued care, etc. There is no indication that the condition is improving, only one of the symptoms. THank you

 

[jdibble]

Is a code of 99332 automatically assigned when the provider states that one of the symptoms is improving? The documentation supports 99233 with all three sections of the E/M. The patient is on an IV, has parental drugs, a consult is requested from a specialty dept to determine continued care, etc. There is no indication that the condition is improving, only one of the symptoms. THank you

Just because one diagnosis is improving does not mean that the patient does not still have other critical issues going on! Without seeing the note it is hard to detemine if the documentation supports a 99233, however as long as 2 of the 3 areas meet the requirements and the medical necessity warrants that level, then a 99233 would be correct. From what you are describing, the patient is still high risk.

Hope that helps!