Question inpatient neuro consult

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Kimball, MI
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I am coding for a neurologist that is doing consults at the hospital. He has been seeing several patients that are showing no brain activity. I am stuck on the MDM part of the equation for the E/M. Obviously it is a high level for the 'table of risk' but for the 'number of diagnoses/management options' there is only a level of 3 points for New Problem - no additional work up planned. BUT it seems to me that I should still be able to give the neurologist the high risk MDM due to the presenting problem. In black and white this is a moderate level but when factoring in the severity of presenting problem it seems high MDM should win? Here is an excerpt from one of the visit notes. This is a subsequent encounter for neuro rather than an initial consult. The initial consult was done by a different neurologist but my thinking remains the same -- I did not include the labs and the radiology results that are also on the encounter (also, I imagine the exam is falling short as well ...):

Assessment/Plan
Massive left hemisphere cerebral infarct involving both ACA and MCA distribution with profound midline shift and herniation
Demonstrating no evidence of brainstem function corneal reflexes absent pupillary light reflex absent no response to painful stimulation
Patient currently DNR family to address comfort care status within next 12 hours
Will continue to follow

Active Diagnoses
Acute CVA (cerebrovascular accident)
CAD (coronary artery disease)

Subjective
The patient is lying in bed, intubated and unresponsive. Her sister is present at the time of the exam, she has not noticed any improvement. Per nursing the patient does not have a gag reflex and is not breathing over the vent. The patient's sister is a former nurse and seems to have a good understanding of the patient's poor prognosis. She is going to discuss a terminal wean with the patient's husband.

Objective
Vitals & Measurements
Systolic Blood Pressure: 127 mmHg Respiratory Rate: 12 br/min Low Apical Heart Rate: 121 bpm High Clinical Weight (kg): 78.3 kg Body Mass Index: 27 kg/m2
Diastolic Blood Pressure: 67 mmHg Oxygen Saturation: 99 % Peripheral Pulse Rate: 120 bpm High
T: 37.7 deg C (Axillary) T: 99.9 deg F (Axillary) TMIN: 98.0 deg F (Oral) TMAX: 37.9 deg C (Oral)

Physical Exam
General: No acute distress, lying in bed, intubated and on a respirator
Neuro: Pupils unresponsive to light bilaterally, corneal responses absent bilaterally, no response to painful in extremities x4. No spontaneous movements.
 

ccollison

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Bay City, Michigan
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The high level of risk for the presenting problem is 4 points, , 2 points for the lab and imaging, 1 point for obtaining history from sister, equals moderate on data, 3 points (moderate) for the dx. So, M,M,H. This still makes the MDM moderate. I agree the exam is a bit low at EPF. HPI is EPF. This comes out to 99232. Hope this helps.

C Collison, CPC, CCC, CPMA, CPPM
 
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5
Location
Kimball, MI
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It does help -- thank you! I think, because it is likely an end of life decision I want to give it a 99233. But because it is a 'new problem - no additional work up planned' then I am sticking with Moderate MDM.

If the exam and the history portions were detailed/comprehensive would I still be using the 99232? In black and white, I know the answer is yes. Of course, though, I keep falling back into the gray .....
 
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