Wiki What level do you get?

[renifejn]

Hospital subsequent note--no CC stated. I'm going back and forth with a co-worker between a 99231 and 99232. Your insite would be appreciated.


Afebrile, on room air, no resp distress, no CP, no dyspnea, no hemoptysis, hemodynamically stable, no vomiting. G-tube feeds held last night.

VS-36.9, 68, 24 98%

PE: sleeping comfortably, HEENT-no nasal flaring, MMM, chest-few crackles at base of right lung, Heart-RRR, ABd +BS, Ext WWP, no cyanosis, + clubbing

A: 20 y/o with CF pulm exacerbation, PI
Plan-Continue Timentin, Amakacin IV
Aggresive Pulm toilet
Monitor glucose
PFT's today

 

[kemptar]

Based on this note I would go with a 99232. Even though the MDM was only straightforward you only need two of the three for these visits. I got EPF for the history and EPF(97) or detailed(95) for the exam. I'd be interested to see what others get.

 

[cdcpc]

I'm leaning more towards a 99232 as well (according to 1995 guidelines).

 

[KellyCPCCPCO]

I would also based on the guidelines go with 99232.

 

[ARCPC9491]

I agree 99232 - based on exam (EPF) and medical decision making. (moderate)