Sadly, yes, I would code this as a 99231. I would like to see more but there is enough.
nsg reports irregular heart beat Chief Complaint
? ongoing issue and has had holter for same Context (sort of) (1 element of HPI)
seems irregular on auscultation 1 element of exam to me as well
will check EKG now at least 1 point in data
You have irregular heart beat for a dx which is going to be at least 2 points for established worsening or 4 points for new w/workup
So You have a problem focused history and exam with low to moderate MDM. Even if you drop history as the 1 element is not so great, you only need 2 of 3 so you can still support it with exam and MDM.
Laura, CPC, CPMA, CEMC
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