# 99231-99233...help



## krssy70 (Feb 23, 2010)

I have a patient that is being seen in the hospital after a hernia repair. Dr. states: Pt feels much better. AF VSS. tol clears w/o pain/n/v, passing flatus
abd: soft, obese, nt, incision c/d/i, some fullness in the incision area c/w a post-op seroma
Will advance diet slowly, add oxycontin to pain regimen for better pain control and overall try to minimize narcotics. Continue in-house care.

Are there any opinions out there in how this should be coded. My take on it is Brief HPI: Qualityt feels much better, Serverity: w/o pain
Pertinent ROS: GI: w/o n/v, passing flatus
Problem focused Exam: Constitution, Abd, Cardiovascular, Skin. 4 systems with 1 bullet each. 
MDM: Prescription drug mgmt, 1 Est prob; stable,improved. No data reveiwed. Straight foward 

I came up with a 99231

Would appreciate any input:

Thank you, 
Kristen


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## cgallimore (Feb 23, 2010)

Did your provider perform the hernia repair?


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## jifnif (Feb 23, 2010)

I would think that this is a POV unless the pt is being seen by another physician for another reason.


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## krssy70 (Feb 23, 2010)

And you are correct, but the patient was discharged and re-admitted with abdominal pain and n/v. Our physician did do that surgery and is now f/u up with the patient now that she is back in the hospital. So this would be billed with a modifier 24 and a diagnosis of 789.00 and 787.01.


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## jifnif (Feb 24, 2010)

I am pretty sure that something of that nature is not paid unless there is a return to the OR.  Not that it can't be billed.  Also, if the icd 9 is pain, the note states no pain.  Just wondering where the support for that would be. But you are correct w/ modifier choice if you do bill it.


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## aguelfi (Feb 24, 2010)

I wouldn't bill for it.  the pain is from the surgery...it's post op care.


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## valleycoder (Feb 24, 2010)

whats the global period for the procedure?  if its not global, i think 99231 is correct, with modifier -24.


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## krssy70 (Feb 25, 2010)

It is global, but my supervisor is telling me that if the pt is re-admitted for a different diag, then it is billable. Not saying that it will be paid, but it is billable. So I posted the question because I was having a hard time trying to distinguish which code to choose, 99231-99233. The documentation is very limited. 
Thanks


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## aguelfi (Mar 1, 2010)

It may be a different diagnosis but if the pain is directly related from having the surgery, I would consider it post-op.  I think about it like this: if the patient was still in the hospital and developed enough pain to stay admitted, I would continue to bill post-op.  My rational thats all.


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## FTessaBartels (Mar 3, 2010)

*1995 guidelines vs 1997 guidelines*

I agree that this hospitalization is not gonna get paid. More and more commercial carriers are following Medicare's lead on the post-op care - if it doesn't require a return to the OR it's global to the surgery.

In any case...

All I see for exam in your note is:   
*abd: soft, obese, nt, incision c/d/i, some fullness in the incision area c/w a post-op seroma*

So unless you miss-typed I do not see constitutional or CV.

Still with 1995 guidelines this would be an expanded problem-focused exam for "limited exam of affected body area or organ system AND other related systems (counting the incision C/D/I and possible seroma as SKIN).  

So with an EPF history and EPF exam you get 99232.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## krssy70 (Mar 5, 2010)

AF = Afib, and VSS = vital signs stable. 1 for cardiovascular and 1 for constitutional.

I utilize the 1997 guidelines which states, should include at least six elements of the Exam for EPF. ??? I'm not counting that. Am I missing something?/?


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## FTessaBartels (Mar 5, 2010)

*Interval history or exam*

I took AF and VSS to be part of the interval history - does not read like exam to me. 

If you are using 1997 guidelines you would have to specify the *values of three vital signs* to get one point for constitutional, so you STILL do not get constitutional exam points for VSS.  

Here's what I see as your only exam:
abd: soft, obese, nt, incision c/d/i, some fullness in the incision area c/w a post-op seroma

If you are using 1997 guidelines - here are the bullet points you can count:
*GI/Abdomen*
* Examination of abdomen with notation of presence of masses or tenderness
* Examination of liver and spleen
* Examination for presence or absence of hernia
* Examination of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
* Obtain stool sample for occult blood test when indicated

*Skin*
* Inspection of skin and subcutatneous tissue (e.g. rashes, lesions, ulcers)
* Palpation of skin and subcutaneous tissue (e.g. induration, subcutaneous nodules, tightening)

I do not see that you get ANY points for abdominal/GI exam if you are using 1997 guidelines. The only bullet point you would get with this documentation would be for skin (because of the incision being C/D/I and the possible seroma) - and I'm being generous there. 


F Tessa Bartels, CPC, CEMC


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## krssy70 (Mar 8, 2010)

Thank you for all of that info. I really appreciate it. It helps alot. My only question is for VSS. Would the physician have to state each vital separately in order to get 1 credit for constitutional? Because the vital signs are documented in the patients inpatient chart, (EMR). This can be something I can educate the physicians on. Again, thank you for your help.


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## FTessaBartels (Mar 8, 2010)

*PHysician must document exam*

The physician must document the exam. This portion of the documentation is a record of the physician's own personal examination of the patient and his/her findings on that exam. 

I really think the notation "VSS" is part of the interval history in this case.  The physician is noting what hospital staff has recorded in the chart since the last visit - i.e. the interval history.

F Tessa Bartels, CPC, CEMC


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