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Brief Note!

  1. #1
    Default Brief Note!
    Medical Coding Books
    I know that a lot of times we have to fish out info to pull together a note to meet a level but this one has me concerned if I am pulling too much:

    nsg reports irregular heart beat
    ? ongoing issue and has had holter for same
    seems irregular on auscultation to me as well
    will check EKG now

    our dr has chosen a 99231. that is all I have. my problem is that I am in a situation where I am to only data enter for this particular group. Sure that is all fine and good but w/in the early part of this year we will be coding from their documentation. These docs think this is okay documentation. Would anyone out there pass this as a 99231 (it is a subsequent visit inpatient)?

  2. #2
    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

  3. #3
    Thanks, I knew it was limited and just barely making the stretch but it does make it. I guess my problem is this note is so brief and I would like to see better documentation. Our drs believe that as long as it makes it, why change the way it is documented! I think they could have done better. on the other end, it makes pt care seem brief to me as well. i wonder what the pt thought at the time?!

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