# Susequent visits 99232 vs 99233



## daniel (Dec 22, 2009)

I would like to now how you few this?

I understand how to count and get the components to get to a Level 3 subsequent visits.

But my question is regarding the MDM. How do you distinguish between a High Complexity and Moderate.


Example: Say you have a patient with all these conditions below and the patient is stable. And doing better, I just don't see how you can get a Moderate decision making with all these Diagnosis being looked over. Even with the patient being stable.

My frustration is distinguishing when to break away from coding multiple CPT 99233 during a patients stay in the hospital.

Please no text book answer here. Real input please. I've read all the articles on this and it's not clear to me yet

Any input on this 


1. Acute hypoxemic resp failure
2. Hemoptysis
3. Pulm HTN
5. pulm edema/CHF
6. OSA

1. Afib with RVR
2. CHF
3. CAD s/p CABG
4. htn
5. Hyperlipidemia


----------



## LLovett (Dec 23, 2009)

Moderate is easy in this case. You have 2 or more chronic illnesses stable, I would also imagine you have Rx management so you have hit it twice on the table of risk. Dx points, if all of those are stable you have 1 point each, you only need 3 to get Moderate.

The other thing to take into consideration with subsequent days is they are 2 of 3. So if you hit a detailed history and detailed exam, even if you only have moderate MDM you would use the 99233. 

My personal experience is the history piece is usually lacking, they are very lazy on the HPI when they are inpatient and into the sub care days. When my providers are documenting enough to support a 99233 it is exam and MDM, our patient is going downhill and qualifies for high. Otherwise the vast majority of my sub care days are 99231s. Crappy histories, no exam, and moderate to high MDM is usually what I end up with.

As far as distinguishing moderate from high with this type of patient you are going to get high in based on data or risk (you already have 4 dx points). If they order labs, x-rays, and order/read an ekg you have 4 data points, added with the dx you have high MDM. If they decided to do an elective major surgery you now have high for risk since you have identified risk factors to go along with your 4 dx points again putting you at high MDM. Obviously there are other combinations those are just fairly common ones I see.

Hopefully this is helpful, it certainly didn't come from any text book its all me! lol

Laura, CPC, CEMC


----------

