Registered: 1321303255 Posts: 773
Reply with quote #1
A hospital progress note...
CC: Abdominal pain.
INTERVAL HISTORY: Patient continues to complain of severe abdominal pain.
EXAM: In moderate distress. BP 144/84, HR 92, RR 22
RESPIRATORY: Lungs CTA. CARDIOVASCULAR: Heart RRR. GI: Abdomen is soft, tender to palpation. PSYCH: Awake and alert. NEURO: No tremors.
Labs: Na 137, K 4.2, Cl 101, CO2 31, BUN 31, creatinine 0.8, glucose 104, HGB 12, HCT 36, PLT 220.
IMPRESSION Worsening pancreatitis Stable diabetes Alcohol dependence, no evidence of active withdrawal
Continue NPO status. Continue IV fluids. Continue current insulin regimen. Continue CIWA protocol to monitor for withdrawal. Start IV Dilaudid, 1 mg Q 4H, PRN. What level of care has been documented? 99231, 99232 or 99233? Click HERE to get the answer.
Registered: 1450369996 Posts: 1
Reply with quote #2
Thank you for this interesting example. I thought that a PFSH was not required for an interval history on a subsequent hospital visit.
Reply with quote #3
I agree with the above, PFSH and ROS don't apply to subsequent visits since it requires an 'interval history' and that information is unlikely to change. However, it didn't matter in this example since the exam and MDM were met appropriately.
I still got it wrong though, I thought it supported 99232 because I underestimated the Diauldid.
Reply with quote #4
Where do I find the answer and explanation?
Reply with quote #5
How do you come up with a detailed exam by 1995 guidelines? It's '2-7 body areas/organ systems, one in detail' and you haven't met that criteria unless 6 organ systems, none in detail is now a Detailed Exam.
Reply with quote #6
A detailed exam is 5 to 7 body areas or organ systems for 95 guidelines. This note addresses 6. Therefore it equals a detailed exam
Reply with quote #7
You can find the explanation on the website under coding rounds and it will say click here for answer which opens a video with a slideshow presentation/breakdown
Registered: 1378902100 Posts: 49
Reply with quote #8
Concurred with answer, but dislike 95 documentation guidelines, except when using what I've always used and that is, the 2-4; 5-7 BA/OS, not the 2-7; 2-7, which, depending on the MAC/payer, the latter may apply. No sir. Don't like 1995 DGs. lol
__________________ Sandy Stevens, CPC, CPMA