# No history hospital visit



## cdcpc (Oct 6, 2008)

I have a situation with a hospital note that has no HPI and no ROS. (if you see any history or ROS elements, please let me know)
The CC is leukocytosis. The exam is detailed and he MDM is moderate. Since this visit is meeting two of the three components with the exam and MDM, can this be billed as a 99232 without any history elements?

Thanks in advance

Hospital note
This 69 year old male seen in the hospital today. He is awake, no complaints.

lab reviewed

OBJECTIVE
VITALS Vital signs stable. Pt is afebrile. 
GENERAL - Patient is WD, WN, male in no acute distress.
HEAD - is atraumatic, normocephalic.
EYES - PERRLA, EOMI, Sclera non-icteric. 
LUNGS -Clear to auscultation bilaterally.
HEART -  Normal S1, S2, no murmur.
ABDOMEN - Soft, NT, ND, pos. bowel sounds throughout.
MS: edema of LE's.

ASSESSMENT:
Diagnosis: Acute respiratory failure--resolved
Diagnosis: Leukocytosis
Diagnosis: Hyponatremia
Diagnosis: Anemia
Diagnosis: Hypokalemia
enterobacter uti
staph a in sputum

PLAN:
agree w Dr. T--disc case w him.* he is going to chg her antibx

disc w family at bedside


99232

-CPT Medical Services: Hospital visit - 99232


----------



## ARCPC9491 (Oct 6, 2008)

Yes, you can use exam and MDM - subsequent inpatient visits require only an "interval history" when using it in the 2 of 3.


----------



## cdcpc (Oct 6, 2008)

I had a feeling the "interval" had something to do with this    So I can base the code off of the exam and MDM levels alone?

I take it you must have passed your CPC E/M--congrats!!!!!


----------



## ARCPC9491 (Oct 6, 2008)

Yes you can.

Thank you for the congrats


----------



## cdcpc (Oct 8, 2008)

*OV no history*

Ok--I have another question--what if I had the same scenario for an office visit?  
I have an established patient with no HPI, but there is a brief ROS and complete PFSH (I know--why do a complete PFSH without going into the HPI?)
The exam is detailed and the MDM is straight-forward.
Technically, we are meeting 2 of the 3 requirements, but since there is no HPI the history element is not met.  Can an established OV code be chosen off the exam and MDM alone?
Thanks


----------



## ARCPC9491 (Oct 8, 2008)

carriedavis7 said:


> Ok--I have another question--what if I had the same scenario for an office visit?
> I have an established patient with no HPI, but there is a brief ROS and complete PFSH (I know--why do a complete PFSH without going into the HPI?)
> The exam is detailed and the MDM is straight-forward.
> Technically, we are meeting 2 of the 3 requirements, but since there is no HPI the history element is not met.  Can an established OV code be chosen off the exam and MDM alone?
> Thanks



Yes ma'am you can  2/3 for established patients. 3/3 for new patients.


----------



## FTessaBartels (Oct 8, 2008)

*Check CPT guidelines*

Carrie,
I know you are trying to be conscientious, but check the guidelines in CPT ... they will tell you whether you need 3 of 3 key elements or only 2 of 3 key elements.   

If it states *2 of 3,* then *any two *will do: History & MDM;  History & Exam; -or-  Exam & MDM
(Although some people like to make sure MDM is one of the two.)

F Tessa Bartels, CPC, CPC-E/M


----------



## cdcpc (Oct 8, 2008)

FTessaBartels said:


> Carrie,
> I know you are trying to be conscientious, but check the guidelines in CPT ... they will tell you whether you need 3 of 3 key elements or only 2 of 3 key elements.
> 
> If it states *2 of 3,* then *any two *will do: History & MDM;  History & Exam; -or-  Exam & MDM
> ...



F Tessa--thanks for the clarification


----------

