# 99231/99232/99233 - How to select correct code?



## prirs1985 (Jan 30, 2018)

For example:

1. 01/28/2018: Patient (initial hospital inpatient care service) admitted for persistent headache nausea. He had a detailed history, a comprehensive examination, and moderate MDM. So 99221 code?
2. 01/39/2018: Patient (subsequent hospital care) was sitting in chair comfortable. He had an expanded problem focused examination, 5 diagnosis problems, 1 lab reviewed, 1 CT scan reviewed, and moderate presenting problem. Which code is correct for subsequent care?

History was already documented during initial visit. Do we still require history for subsequent care? Please clarify.


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## kroemer4 (Jan 30, 2018)

For example:

1. 01/28/2018: Patient (initial hospital inpatient care service) admitted for persistent headache nausea. He had a detailed history, a comprehensive examination, and moderate MDM. So 99221 code? Yes, D+C+M = 99221
2. 01/39/2018: Patient (subsequent hospital care) was sitting in chair comfortable. He had an expanded problem focused examination, 5 diagnosis problems, 1 lab reviewed, 1 CT scan reviewed, and moderate presenting problem. Which code is correct for subsequent care? EXPF Exam + Moderate MDM = 99232

History was already documented during initial visit. Do we still require history for subsequent care? Please clarify. Subsequent care is 2 of 3 components. From the auditing perspective, I would suggest an interval hx simply for documentation purposes: "No changes; see DOS xx/xx/xxxx for full history" would work; not "countable" per se for an element, but documented so the reader knows it wasn't forgotten/overlooked. A chief complaint to support this visit is required, though. Something that supports the need for the encounter and the bill for services, and not just "follow up" or "progress note".


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## prirs1985 (Feb 1, 2018)

kroemer4 said:


> For example:
> 
> 1. 01/28/2018: Patient (initial hospital inpatient care service) admitted for persistent headache nausea. He had a detailed history, a comprehensive examination, and moderate MDM. So 99221 code? Yes, D+C+M = 99221
> 2. 01/39/2018: Patient (subsequent hospital care) was sitting in chair comfortable. He had an expanded problem focused examination, 5 diagnosis problems, 1 lab reviewed, 1 CT scan reviewed, and moderate presenting problem. Which code is correct for subsequent care? EXPF Exam + Moderate MDM = 99232
> ...



Thank you for reply. During initial visit, physician A examined a patient. Later, physician B examined a patient for subsequent care. Of course, physician B will spend time to check chart review in details. 99232 code is still correct for subsequent care?


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