Pediatric Coding Alert

Question: The distinction between the documentation requirements for CPT 99231 and 99232 is not very clear. Must new orders accompany 99232?

Answer: There are several distinctions between 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires two of three components) and 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires two of three components). The history and examination portion for 99232 are expanded problem focused as compared to the 99231, which is only problem focused. The main issue is the medical decision-making, which is moderate for 99232 and only straightforward or low for 99231.

A review of Appendix C Clinical Examples of CPT sheds a little more light on patients in the 99232 category. These patients are responding inadequately to treatment or have a "new problem" that needs to be treated. This means the physician treats the patient with a variety of options. There are new tests, procedures, drug administration and plans. Should there be new orders? Yes. Because the patient is not responding to present treatment properly or has a new problem, which will need treatment, you should see new orders for the tests, procedures, etc.