99231 - Subs Hospital visit has the following requirements. You only need to meet TWO out of three.
Problem focused INTERVAL history
Problem focused exam
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
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join