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No history hospital visit

  1. #1
    Question No history hospital visit
    Exam Training Packages
    I have a situation with a hospital note that has no HPI and no ROS. (if you see any history or ROS elements, please let me know)
    The CC is leukocytosis. The exam is detailed and he MDM is moderate. Since this visit is meeting two of the three components with the exam and MDM, can this be billed as a 99232 without any history elements?

    Thanks in advance

    Hospital note
    This 69 year old male seen in the hospital today. He is awake, no complaints.

    lab reviewed

    OBJECTIVE
    VITALS Vital signs stable. Pt is afebrile.
    GENERAL - Patient is WD, WN, male in no acute distress.
    HEAD - is atraumatic, normocephalic.
    EYES - PERRLA, EOMI, Sclera non-icteric.
    LUNGS -Clear to auscultation bilaterally.
    HEART - Normal S1, S2, no murmur.
    ABDOMEN - Soft, NT, ND, pos. bowel sounds throughout.
    MS: edema of LE's.

    ASSESSMENT:
    Diagnosis: Acute respiratory failure--resolved
    Diagnosis: Leukocytosis
    Diagnosis: Hyponatremia
    Diagnosis: Anemia
    Diagnosis: Hypokalemia
    enterobacter uti
    staph a in sputum

    PLAN:
    agree w Dr. T--disc case w him.* he is going to chg her antibx

    disc w family at bedside


    99232

    -CPT Medical Services: Hospital visit - 99232

  2. #2
    Default
    Yes, you can use exam and MDM - subsequent inpatient visits require only an "interval history" when using it in the 2 of 3.

  3. #3
    Default
    I had a feeling the "interval" had something to do with this So I can base the code off of the exam and MDM levels alone?

    I take it you must have passed your CPC E/M--congrats!!!!!
    Last edited by cdcpc; 10-06-2008 at 03:00 PM. Reason: add congrats
    Carrie, BS, CPC

  4. #4
    Default
    Yes you can.

    Thank you for the congrats

  5. #5
    Default OV no history
    Ok--I have another question--what if I had the same scenario for an office visit?
    I have an established patient with no HPI, but there is a brief ROS and complete PFSH (I know--why do a complete PFSH without going into the HPI?)
    The exam is detailed and the MDM is straight-forward.
    Technically, we are meeting 2 of the 3 requirements, but since there is no HPI the history element is not met. Can an established OV code be chosen off the exam and MDM alone?
    Thanks
    Carrie, BS, CPC

  6. #6
    Default
    Quote Originally Posted by carriedavis7 View Post
    Ok--I have another question--what if I had the same scenario for an office visit?
    I have an established patient with no HPI, but there is a brief ROS and complete PFSH (I know--why do a complete PFSH without going into the HPI?)
    The exam is detailed and the MDM is straight-forward.
    Technically, we are meeting 2 of the 3 requirements, but since there is no HPI the history element is not met. Can an established OV code be chosen off the exam and MDM alone?
    Thanks
    Yes ma'am you can 2/3 for established patients. 3/3 for new patients.

  7. #7
    Location
    Milwaukee WI
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    4,466
    Default Check CPT guidelines
    Carrie,
    I know you are trying to be conscientious, but check the guidelines in CPT ... they will tell you whether you need 3 of 3 key elements or only 2 of 3 key elements.

    If it states 2 of 3, then any two will do: History & MDM; History & Exam; -or- Exam & MDM
    (Although some people like to make sure MDM is one of the two.)

    F Tessa Bartels, CPC, CPC-E/M

  8. #8
    Default
    Quote Originally Posted by FTessaBartels View Post
    Carrie,
    I know you are trying to be conscientious, but check the guidelines in CPT ... they will tell you whether you need 3 of 3 key elements or only 2 of 3 key elements.

    If it states 2 of 3, then any two will do: History & MDM; History & Exam; -or- Exam & MDM
    (Although some people like to make sure MDM is one of the two.)

    F Tessa Bartels, CPC, CPC-E/M
    F Tessa--thanks for the clarification
    Carrie, BS, CPC

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