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Does this meet a 99231?

  1. #1
    Default Does this meet a 99231?
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    Would someone mind looking at this note and telling me if they think this meets a 99231? I feel that the dr walked into the room and looked at the pt and that is the end of it. Or does she get it b/c she reviewed Labs in EMR? Am I missing something? The pt is on the way to hospice, so this is like a courtesy check.

    Acute diastolic CHF
    B/L LL PNA new infiltrate R
    S/P VDRF extubated 1/31
    Paraproteinemia likley Waldernstrom's macroglobulinemia
    Bilateral lower extremity cellulitis right more than left improving
    Left eye trauma
    Acute renal failure on chronic kidney disease again worsening renal function
    Ambulatory dysfunction
    ? renal mass

    Status post right herpetic lesion of the trigeminal nerve herpes zoster
    Chronic lower extremity lymphedema
    Congestive heart failure
    Myeloproliferative disease with thrombocytosis
    Macular degeneration

    hospice consult awaited
    comfort care
    level 4 code

    less responsive

    Physical Examination
    General Appearance: Drowsy, Frail
    HEENT: Mucous Membranes Dry

    Clinical Data-
    Labs: All labs have been reviewed in the EMR.

  2. #2
    Milwaukee WI
    Default 99231 requirements
    99231 - Subs Hospital visit has the following requirements. You only need to meet TWO out of three.

    Problem focused INTERVAL history
    Problem focused exam
    Straightfoward MDM

    There's no question about MDM in this case.

    Your "exam" would qualify as problem focused (1-5 bullets on 1997) BUT
    The problem with this note is I have no idea what the chief complaint is. Based on the Impression and Diagnoses listed I'd say patient was in hospital for TIA or CHF or even, perhaps a fall? (eye trauma - how did that happen?)
    I like to see a "problem focused" exam at least relate to the problem.

    So I'm on the fence about this one. I think your physician probably DID perform the services of a 99231 or perhaps 99232, but it's not well documented.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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