Question Can you help me level this visit? 99233 vs 99232

indynne

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This is a split share for an inpatient follow-up visit. My doctor wants 99233, but I think his documentation might only support 99232. This is the entirety of his portion of the E/M:

"I am seeing her in follow-up for ESRD management and dialysis needs. Patient has been moved to ICU yesterday night after her blood pressure was persistently staying low. I reviewed her labs from today. Her blood pressure slightly better. She has chronic hypotension. Continue midodrine. Will do hemodialysis today for 3 hours to pull two L if tolerated. Continue antibiotic for her UTI. We can keep the patient one more day in the ICU to see how her blood pressure does today after dialysis. Blood cultures are pending at this point to rule out sepsis."

Any help is appreciated!
 
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