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What level do you get?

  1. Default What level do you get?
    Medical Coding Books
    Hospital subsequent note--no CC stated. I'm going back and forth with a co-worker between a 99231 and 99232. Your insite would be appreciated.

    Afebrile, on room air, no resp distress, no CP, no dyspnea, no hemoptysis, hemodynamically stable, no vomiting. G-tube feeds held last night.

    VS-36.9, 68, 24 98%

    PE: sleeping comfortably, HEENT-no nasal flaring, MMM, chest-few crackles at base of right lung, Heart-RRR, ABd +BS, Ext WWP, no cyanosis, + clubbing

    A: 20 y/o with CF pulm exacerbation, PI
    Plan-Continue Timentin, Amakacin IV
    Aggresive Pulm toilet
    Monitor glucose
    PFT's today

  2. Default
    Based on this note I would go with a 99232. Even though the MDM was only straightforward you only need two of the three for these visits. I got EPF for the history and EPF(97) or detailed(95) for the exam. I'd be interested to see what others get.

  3. #3
    I'm leaning more towards a 99232 as well (according to 1995 guidelines).
    Carrie, BS, CPC

  4. Default
    I would also based on the guidelines go with 99232.
    Kelly Long CPC, CFE
    Manager Audit and Compliance

  5. #5
    I agree 99232 - based on exam (EPF) and medical decision making. (moderate)

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