Wiki Subsequent Hospital Visit

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jifnif

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I have a visit that I am questioning the level. could someone help me with this report? Our dr is saying it is Moderate Complexity and I have it as Low.

Impression
-
Lupus psychosis
Lupus
Seizure d/o
HTN

Plan
-
her behaviour makes me suspect more of supratentorial issues then purely lupus given spoke to rheum yestrerday and today withdrawn and every nsg attempt in vain
will d/w penn foundation possible admission to their unit
did recieve mirtazapine but her demeneour is more suspicious of pschosis then med effect
consultants appreciated
rheum w/u pending but N ESR favours against any acute processes

Subjective
-
resting in bed sleeping and withdraws to touch bit will not talk,make eye contact or arouse

Physical Examination
General Appearance: No Apparent Distress
Cardiovascular: Regular Rate/Rhythm
Lungs: Clear Auscult./Percussion
Abdomen: Soft, Non-Tender, Bowel Sounds Active
Neuro: - (resting,withdrawn,avoids eye contact and any attempts to converse)

Clinical Data
-
Labs: All labs have been reviewed in the EMR.
:confused:
 
I agree with your provider, 99232. The only thing that concerns me is lack of a chief complaint.

You have an EPF exam and you have an undiagnosed new problem with uncertain prognosis and more than 4 dx points so you have moderate risk.

Just my opinion,

Laura, CPC, CEMC
 
It is my understanding that whatever is used in the impression or to be used as a supported code must have supporting documentation that it was either monitored, evaluated, assessed or treated. Wouldn't this report fall short of that for seizure and hypertension? Basically the dr is only addressing the lupus/psychosis vs rheum.
 
Just bumping this one up because it is still a question in my mind about the MEAT= measured, evaluated, assessed or treated. to use as supported documentation. thanks again!
 
You don't need those 2 dx to support moderate in this case, in my opinion, but I think they are playing a part in his MDM even if he is not directly managing them.

It looks to me the psychosis is new, which would be a minimum of 3 dx points if you throw out the other dx, and as I stated previously I counted this as an undiagnosed new problem because he is unsure and asking for another specialists opinion.

Laura, CPC, CEMC
 
subsequent hospital 99232

i was present. i saw and discussed infant with staff on rounds.
resp-stable
cv-f/u w cardiology
ger-will continue zantac and reglan
fen-neosure??
wt 5010

please tell me how this is 99232?
 
It isn't.

In fact, I can't pull enough out to bill anything.

No chief complaint, no real history about the patient, resp stable seems more of an assesment than exam element to me, so all you have is MDM and weight. This isn't even documented in a way to support a note by a resident.

Laura, CPC, CEMC
 
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