Wiki Does this meet a 99231?

[jifnif]

Would someone mind looking at this note and telling me if they think this meets a 99231? I feel that the dr walked into the room and looked at the pt and that is the end of it. Or does she get it b/c she reviewed Labs in EMR? Am I missing something? The pt is on the way to hospice, so this is like a courtesy check.

Impression-
Acute diastolic CHF
B/L LL PNA new infiltrate R
S/P VDRF extubated 1/31
Dysphagia
Paraproteinemia likley Waldernstrom's macroglobulinemia
Thrombocytosis
TIA
Bilateral lower extremity cellulitis right more than left improving
Left eye trauma
Acute renal failure on chronic kidney disease again worsening renal function
Ambulatory dysfunction
? renal mass


OTHER DIAGNOSES:
Status post right herpetic lesion of the trigeminal nerve herpes zoster
Chronic lower extremity lymphedema
Congestive heart failure
Hypothyroidism
Myeloproliferative disease with thrombocytosis
Macular degeneration

Plan-
hospice consult awaited
comfort care
level 4 code

Subjective-
comfortable
less responsive

Physical Examination
General Appearance: Drowsy, Frail
HEENT: Mucous Membranes Dry

Clinical Data-
Labs: All labs have been reviewed in the EMR.

 

[FTessaBartels]

99231 requirements

99231 - Subs Hospital visit has the following requirements. You only need to meet TWO out of three.

Problem focused INTERVAL history
Problem focused exam
Straightfoward MDM

There's no question about MDM in this case.

Your "exam" would qualify as problem focused (1-5 bullets on 1997) BUT
The problem with this note is I have no idea what the chief complaint is. Based on the Impression and Diagnoses listed I'd say patient was in hospital for TIA or CHF or even, perhaps a fall? (eye trauma - how did that happen?)
I like to see a "problem focused" exam at least relate to the problem.

So I'm on the fence about this one. I think your physician probably DID perform the services of a 99231 or perhaps 99232, but it's not well documented.

Hope that helps.

F Tessa Bartels, CPC, CEMC