AAPC - Back to school
Results 1 to 2 of 2

Thread: Help with coding Inpatient visit

  1. #1
    Join Date
    Apr 2007
    Daytona Beach, FL

    Question Help with coding Inpatient visit

    AAPC: Back to School
    What level E/M would I be able to assign in the following situation:

    I am auditing an initial inpatient visit where the doctor was evaluating a 96 year old woman who fell. It was unclear if the patient had syncope or why she fell. The HPI was brief and there was no ROS or PFSH because the patient refused to answer any questions. The doctor noted that past medical records were not available to review. The doctor obtained vitals and noted that pt was agitated, but the patient refused the rest of the exam. The doctor reviewed labs and xrays obtained and ordered more tests for the next day and IV fluids. MDM was moderate.

    The doctor billed a 99223. Based on what was documented I cannot even come up with a low level inpatient visit. What level should this be? If a patient is unable to cooperate and answer questions for the HPI and ROS or refuses, can you code a visit higher or do you have to code as is documented?

    Jodi Dibble, CPC
    Last edited by jdibble; 03-10-2010 at 01:34 PM.

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default At least 3d posting of same question

    Please see other forums where this same question was posted as I have answered there.

    Please, coders ... take a look at the various forums and choose the ONE forum that is most appropriate for your question. Posting multiple times will not give you a better answer than posting once in the right place.

    F Tessa Bartels, CPC, CEMC

Similar Threads

  1. Replies: 1
    Last Post: 04-08-2014, 01:52 PM
  2. Inpatient New Visit E/M
    By banjocat in forum E/M
    Replies: 3
    Last Post: 01-02-2014, 06:17 AM
  3. inpatient visit along with ov
    By genawaller in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 01-05-2012, 11:22 AM
  4. DX for global visit while inpatient?
    By kjstearns in forum Diagnosis Coding
    Replies: 0
    Last Post: 09-09-2011, 02:50 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.