Wiki 99231-99233...help

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krssy70

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I have a patient that is being seen in the hospital after a hernia repair. Dr. states: Pt feels much better. AF VSS. tol clears w/o pain/n/v, passing flatus
abd: soft, obese, nt, incision c/d/i, some fullness in the incision area c/w a post-op seroma
Will advance diet slowly, add oxycontin to pain regimen for better pain control and overall try to minimize narcotics. Continue in-house care.

Are there any opinions out there in how this should be coded. My take on it is Brief HPI: Quality:pt feels much better, Serverity: w/o pain
Pertinent ROS: GI: w/o n/v, passing flatus
Problem focused Exam: Constitution, Abd, Cardiovascular, Skin. 4 systems with 1 bullet each.
MDM: Prescription drug mgmt, 1 Est prob; stable,improved. No data reveiwed. Straight foward

I came up with a 99231

Would appreciate any input:

Thank you,
Kristen
 
And you are correct, but the patient was discharged and re-admitted with abdominal pain and n/v. Our physician did do that surgery and is now f/u up with the patient now that she is back in the hospital. So this would be billed with a modifier 24 and a diagnosis of 789.00 and 787.01.
 
I am pretty sure that something of that nature is not paid unless there is a return to the OR. Not that it can't be billed. Also, if the icd 9 is pain, the note states no pain. Just wondering where the support for that would be. But you are correct w/ modifier choice if you do bill it.
 
It is global, but my supervisor is telling me that if the pt is re-admitted for a different diag, then it is billable. Not saying that it will be paid, but it is billable. So I posted the question because I was having a hard time trying to distinguish which code to choose, 99231-99233. The documentation is very limited.
Thanks
 
It may be a different diagnosis but if the pain is directly related from having the surgery, I would consider it post-op. I think about it like this: if the patient was still in the hospital and developed enough pain to stay admitted, I would continue to bill post-op. My rational thats all.
 
1995 guidelines vs 1997 guidelines

I agree that this hospitalization is not gonna get paid. More and more commercial carriers are following Medicare's lead on the post-op care - if it doesn't require a return to the OR it's global to the surgery.

In any case...

All I see for exam in your note is:
abd: soft, obese, nt, incision c/d/i, some fullness in the incision area c/w a post-op seroma

So unless you miss-typed I do not see constitutional or CV.

Still with 1995 guidelines this would be an expanded problem-focused exam for "limited exam of affected body area or organ system AND other related systems (counting the incision C/D/I and possible seroma as SKIN).

So with an EPF history and EPF exam you get 99232.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
AF = Afib, and VSS = vital signs stable. 1 for cardiovascular and 1 for constitutional.

I utilize the 1997 guidelines which states, should include at least six elements of the Exam for EPF. ??? I'm not counting that. Am I missing something?/?
 
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Interval history or exam

I took AF and VSS to be part of the interval history - does not read like exam to me.

If you are using 1997 guidelines you would have to specify the values of three vital signs to get one point for constitutional, so you STILL do not get constitutional exam points for VSS.

Here's what I see as your only exam:
abd: soft, obese, nt, incision c/d/i, some fullness in the incision area c/w a post-op seroma

If you are using 1997 guidelines - here are the bullet points you can count:
GI/Abdomen
* Examination of abdomen with notation of presence of masses or tenderness
* Examination of liver and spleen
* Examination for presence or absence of hernia
* Examination of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
* Obtain stool sample for occult blood test when indicated

Skin
* Inspection of skin and subcutatneous tissue (e.g. rashes, lesions, ulcers)
* Palpation of skin and subcutaneous tissue (e.g. induration, subcutaneous nodules, tightening)

I do not see that you get ANY points for abdominal/GI exam if you are using 1997 guidelines. The only bullet point you would get with this documentation would be for skin (because of the incision being C/D/I and the possible seroma) - and I'm being generous there.


F Tessa Bartels, CPC, CEMC
 
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Thank you for all of that info. I really appreciate it. It helps alot. My only question is for VSS. Would the physician have to state each vital separately in order to get 1 credit for constitutional? Because the vital signs are documented in the patients inpatient chart, (EMR). This can be something I can educate the physicians on. Again, thank you for your help. :)
 
PHysician must document exam

The physician must document the exam. This portion of the documentation is a record of the physician's own personal examination of the patient and his/her findings on that exam.

I really think the notation "VSS" is part of the interval history in this case. The physician is noting what hospital staff has recorded in the chart since the last visit - i.e. the interval history.

F Tessa Bartels, CPC, CEMC
 
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