# Documentation Required for 99232?



## dhuston (Jun 9, 2009)

Since we're a radiology group our hospital follow ups to the IR procedures are normally 99231.  But now the group wants to do a new procedure which (per Society of Interventional Radiology) would fall under a hospital follow up code.  I'm wondering what would be required to bill a 99232 for these.

The situation is that we've previously placed a chest tube (no global) for empyema and now the tube by itself isn't resolving the problem (there's my moderate complexity decision making).  So the doctor injects tPA into the tube to help resolve the empyema.

I believe I only need either history or exam but not both.  Exam is going to be limited to one area which would be problem focused.  So we're left with history.  What do I need in the history for expanded problem focused?

Thanks,
Diane Huston, CPC,RCC


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## Karolina (Jun 9, 2009)

An EPF hx requires 1-3 HPI and 1 ROS. Also, if the exam covers two systems/areas it would be EPF, e.g., checking vital signs and looking at the skin around the tube. Keep in mind that it must be medically necessary.


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## dhuston (Jun 9, 2009)

Thanks for answering.  I think it's the history that has me confused.  If there was only 1 HPI and 1 ROS wouldn't that be the lower level problem focused 99231?  Or is problem focused just 1 of either?

Thanks.
Diane


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## Karolina (Jun 9, 2009)

In the history, if you have 1, 2 or 3 HPI you satisfy HPI for problem focused as well as expanded problem focused. If you do not have any ROS your history is problem focused. If you do have at least 1 ROS you will have an expanded problem focused hx. In other words - without any ROS all you can get is the lowest level of history: problem focused. If you do have 1 ROS *and* 1, 2, or 3 HPI you have an expanded problem focused history.
The history builds up from the bottom to the top, starting with the chief complaint (always required), your next layer is the HPI, then you add another layer - the ROS, and finally top it off with the PFSH (which is not required for the daily care codes). 
Hope this makes sense to you.


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## dhuston (Jun 9, 2009)

Ahhhh, now I understand.  Thanks!!!


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