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Critical care, please code

  1. Unhappy Critical care, please code
    Medical Coding Books
    Hi all,

    I am still getting a grasp on Critical Care I need your help, please :0)

    Can someone code this hospital progress note and give me your feedback, I say this would be a 99231.

    Interval history- Sleepy pt doing much better now.

    Systems reviewed: Resp, GI, GU, CV, constitutional, neuro


    The status of 3 vitals, pt is malnourished
    Eyes: sclera aniecteric, PERRL, EOMI
    ENMT: normal ears/nose, normal hearing, normal teeth and gums, dry mouth
    Neck: normal JVP, no mass
    Resp: normal resp effort, normal breathing sounds,
    CV: normal rhythm, no edema
    GI: soft, no masses, normal bowel sounds
    LN: normal cervical
    M/S: normal ROM
    Skin: no clubbing or cyanosis, no rash or ulcer
    Neuro: normal sensation, normal muscle strength, normal reflexes
    Psych: normal affect, AOX3, normal judgment and insight


    1. Acute renal failure - Non-oliguric, dehydration improved rapidly, positive urine output.

    2. Anemia - Improved S/P blood transfusion, no need for EPO at this point.
    3. Pneumonia - Improving clinically, increase Levaquin dosage

    My physician billed this a level 3 progress note. I am on the fence with this one... I say it is a level 1 progress note because the conditions are improving and on the other side of that I say it is a level 3 because diagnosis that this patient has. Any insight would be greatly appreciated!


  2. #2
    I would say it is a 99232, with the exam and the moderate MDM, I would code 232. Since the patient is improving it would not be high but still the patient is sick with multiple Dx so it would be moderate.

    I hope this helps some,


    "Life isn't about waiting for the storm to pass...It's about learning to dance in the rain."

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