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someone please check this

  1. #1
    Default someone please check this
    Medical Coding Books
    Would someone please double check this history. I have audited about 7 charts and I have not agreed with his final e/m code on any of them. This is a Subsequent hospital care.

    SUBJECTIVE: The patient says her dyspnea has improved. She still feels fatigued. Other than over the counter medication for her osteoarthritis that she gets from the herbal supplement store, she has not been on any new medications.

    PHYSICAL EXAMINATION:

    Vitals Signs: Her heart rate has been between 40 and 48, respiratory rate is 18, blood pressure is 167/67. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive. CARDIOVASCULAR: She is bradycardic. LUNGS: Her lungs are clear bilaterally. ABDOMEN: Her abdomen is nontender, nondistended. EXTREMITIES: No cyanosis, clubbing or edema\


    Besides the Assessment and Plan, that is all the charting.

    He is getting a 99232.

  2. #2
    Location
    Kingsport, TN
    Posts
    149
    Default
    In my opinion, unless there is some type of complication documented elsewhere this does not qualify for 99232. That's just my thoughts...

  3. #3
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by julia9723 View Post
    Would someone please double check this history. I have audited about 7 charts and I have not agreed with his final e/m code on any of them. This is a Subsequent hospital care.

    SUBJECTIVE: The patient says her dyspnea has improved. She still feels fatigued. Other than over the counter medication for her osteoarthritis that she gets from the herbal supplement store, she has not been on any new medications.

    PHYSICAL EXAMINATION:

    Vitals Signs: Her heart rate has been between 40 and 48, respiratory rate is 18, blood pressure is 167/67. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive. CARDIOVASCULAR: She is bradycardic. LUNGS: Her lungs are clear bilaterally. ABDOMEN: Her abdomen is nontender, nondistended. EXTREMITIES: No cyanosis, clubbing or edema\


    Besides the Assessment and Plan, that is all the charting.

    He is getting a 99232.
    Looks more like a 99231, stable improving.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  4. #4
    Location
    Ellenville, New York
    Posts
    1,176
    Default agree with 99231
    Even with the exam level being detailed' (a stretch at best) I can't see this beyond level 1 due to the improvement of the pt. Nature of presenting problem...

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  5. #5
    Default I have to agree with 99232, if there is a chief complaint
    If there is no chief complaint it is not billable at all.

    Otherwise this is subsequent care, 2 of 3 required, EPF history, EPF exam, Moderate MDM.

    EPF history-1 HPI element and 1 ROS, that is covered
    EPF exam- 6 bullets on 97 or 2 organ systems 95, that is covered both ways
    Moderate MDM- who knows since it wasn't posted but we already met the requirements for a 99232 with history and exam.

    Laura, CPC, CPMA, CEMC

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