I have a situation with a hospital note that has no HPI and no ROS. (if you see any history or ROS elements, please let me know)
The CC is leukocytosis. The exam is detailed and he MDM is moderate. Since this visit is meeting two of the three components with the exam and MDM, can this be billed as a 99232 without any history elements?
Thanks in advance
Hospital note
This 69 year old male seen in the hospital today. He is awake, no complaints.
lab reviewed
OBJECTIVE
VITALS Vital signs stable. Pt is afebrile.
GENERAL - Patient is WD, WN, male in no acute distress.
HEAD - is atraumatic, normocephalic.
EYES - PERRLA, EOMI, Sclera non-icteric.
LUNGS -Clear to auscultation bilaterally.
HEART - Normal S1, S2, no murmur.
ABDOMEN - Soft, NT, ND, pos. bowel sounds throughout.
MS: edema of LE's.
ASSESSMENT:
Diagnosis: Acute respiratory failure--resolved
Diagnosis: Leukocytosis
Diagnosis: Hyponatremia
Diagnosis: Anemia
Diagnosis: Hypokalemia
enterobacter uti
staph a in sputum
PLAN:
agree w Dr. T--disc case w him.* he is going to chg her antibx
disc w family at bedside
99232
-CPT Medical Services: Hospital visit - 99232
The CC is leukocytosis. The exam is detailed and he MDM is moderate. Since this visit is meeting two of the three components with the exam and MDM, can this be billed as a 99232 without any history elements?
Thanks in advance
Hospital note
This 69 year old male seen in the hospital today. He is awake, no complaints.
lab reviewed
OBJECTIVE
VITALS Vital signs stable. Pt is afebrile.
GENERAL - Patient is WD, WN, male in no acute distress.
HEAD - is atraumatic, normocephalic.
EYES - PERRLA, EOMI, Sclera non-icteric.
LUNGS -Clear to auscultation bilaterally.
HEART - Normal S1, S2, no murmur.
ABDOMEN - Soft, NT, ND, pos. bowel sounds throughout.
MS: edema of LE's.
ASSESSMENT:
Diagnosis: Acute respiratory failure--resolved
Diagnosis: Leukocytosis
Diagnosis: Hyponatremia
Diagnosis: Anemia
Diagnosis: Hypokalemia
enterobacter uti
staph a in sputum
PLAN:
agree w Dr. T--disc case w him.* he is going to chg her antibx
disc w family at bedside
99232
-CPT Medical Services: Hospital visit - 99232