A neurologist sees a patient in the hospital on follow up. Detailed exam is documented. For MDM notes:
No new symptoms.
2. L facial weakness -Bell's Palsy
3. Parkinsons Disease (outpt f/u with neurologist)Though this is better than some notes I have seen, it is still weak. You can report the syncope, but not the TIA because it is yet unknown, you can also use Bell's Palsy and Parkinsons So for the Number of DX or TX options you have 3.
MRI head to my review, no evidence of acute infarct. Continue ASA/Plavix
Awaiting formal report MRI and 2 D echo. If both neg no indication for further neurologic workup. Amount/complexity of data I believe to be 3, 1 point for radiology order, 2 points for independent visualization of the timage. (at least it seems that he viewed it himself and is awaiting radiology for final.
Will sign off for now, please recall prn. Table of Risks: Presenting Problem is High - possible TIA, Tests ordered, is moderate, and Management options is moderate, making the overall risk factor to be moderate. So, you have Moderate number of DX/TX options; Moderate Amount/Complexity for review; Moderate risk, making your MDM moderate.
Is this high risk because of the TIA even though there is no further symptoms? How many diagnosis would be counted? Is one stable problem counted that would only meet 99231?
With your detailed exam and your moderate MDM, you should be able to report 99232 for your visit.
Hope this helps, and that it is correct. Difficult to know for sure with the note.
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