Question Is this an E&M?


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I'm not even sure what to do with this one!

Subsequent hospital day. Patient was actually in pre-op holding area. (CT shows ruptured bladder/bladder tear on dome, urologist was set to repair.) Surgery discussed in detail with patient the day before. Of note: patient was in MVA that caused injury. Doctor noted patient "seemed shaky but otherwise OK".
As soon as doctor appeared, before he spoke a word, patient went ballistic. Accused him (and rest of hospital staff) of "not talking to her", "not telling her everything that was wrong with her". Refused to sign surgery consent. Doctor conferred via phone with nurse on floor that was attending to patient, who reported drugs in patients' tox screen, patient was abusive and attempted to strike the nurses.
Bottom line, surgery was cancelled. Belief is untreated mental illness that needs to be addressed by proper professional. Doctor states he spent 45 minutes with patient.

I can pull an HPI (location and context) from this, and an MDM. Pertinent ROS, kind of - psychiatric, based on patient's demeanor. No true physical exam was done, clearly. But I'm worried that it's a STRETCH and a grasp at straws.

This is the first time I can remember seeing something like this, so I will welcome any and all feedback. Thank you! :)


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I think you have 99231 since you have at least a problem-focused history and straightforward MDM, and only 2 components are required for a subsequent hospital visit. I do think you also have 1 constitutional or psych ROS since the patient was abusive.