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

[prirs1985]

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.

 

[kroemer4]

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".

 

[prirs1985]

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".

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?