Wiki New patient, pregnant, 23 weeks, spotting hospital exam

[desireewhite185@yahoo.com]

Hello,
I was hoping for some advice on CPT for a New patient who came to our hospital for vaginal bleeding at 23 weeks. She was not seen in the Emergency room. Looks like she went to our delivery floor, she had Non-stress test and our doctor on call gave her an exam.
He submitted CPT 99234, low severity 45 minutes, but looks like this code is for “observation” admitted and D/C same date and it looks like she was outpatient..
He did not note time in his note.
Here's the note, what do you think would be best code? E/M 99203? Ty! (I will enter for the NST reading, which is a separate note)

 

[nielynco]

Hello,
I was hoping for some advice on CPT for a New patient who came to our hospital for vaginal bleeding at 23 weeks. She was not seen in the Emergency room. Looks like she went to our delivery floor, she had Non-stress test and our doctor on call gave her an exam.
He submitted CPT 99234, low severity 45 minutes, but looks like this code is for “observation” admitted and D/C same date and it looks like she was outpatient..
He did not note time in his note.
Here's the note, what do you think would be best code? E/M 99203? Ty! (I will enter for the NST reading, which is a separate note)

View attachment 8105

I would agree that 99203 is appropriate as the patient does not seem to have been admitted to observation and time was not documented. The provider has already identified that he/she thought MDM was of low complexity.