Neurology & Pain Management Coding Alert

Question: I have physician documentation stating that an inpatient "continues to have left retro-orbital headache; has decreased to 5/10 with intramuscular triptan." The provider performed a problem focused exam and moderate complexity medical decision making. Should this subsequent hospital care be reported with 99231 or 99232?

Florida Subscriber

Answer: Use code 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit) in this instance. The scenario described includes a brief history of present illness (HPI), noting the location, severity, and modifying factor present. On the other hand, 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity...) requires an expanded problem focused interval history, which should include a brief HPI (one to three elements) plus a problem-pertinent review of systems (ROS), or an inquiry about the system directly related to the problem(s) identified in HPI. If your neurologist had included documentation of his questions regarding the neurologic system (such as "Patient denies any radiation of pain, but complains of some upper extremity paresthesia."), you could select 99232.

FYI: "Interval history" refers to any change in the patient's history since the last history was taken. All levels of subsequent hospital care include reviewing the patient's medical record and reviewing the results of any diagnostic studies or changes in the patient's status since the physician's last assessment.