jdibble
True Blue
What level E/M would I be able to assign in the following situation:
I am auditing an initial inpatient visit where the doctor was evaluating a 96 year old woman who fell. It was unclear if the patient had syncope or why she fell. The HPI was brief and there was no ROS or PFSH because the patient refused to answer any questions. The doctor noted that past medical records were not available to review. The doctor obtained vitals and noted that pt was agitated, but the patient refused the rest of the exam. The doctor reviewed labs and xrays obtained and ordered more tests for the next day and IV fluids. MDM was moderate.
The doctor billed a 99223. Based on what was documented I cannot even come up with a low level inpatient visit. What level should this be? If a patient is unable to cooperate and answer questions for the HPI and ROS or refuses, can you code a visit higher or do you have to code as is documented?
Jodi Dibble, CPC
I am auditing an initial inpatient visit where the doctor was evaluating a 96 year old woman who fell. It was unclear if the patient had syncope or why she fell. The HPI was brief and there was no ROS or PFSH because the patient refused to answer any questions. The doctor noted that past medical records were not available to review. The doctor obtained vitals and noted that pt was agitated, but the patient refused the rest of the exam. The doctor reviewed labs and xrays obtained and ordered more tests for the next day and IV fluids. MDM was moderate.
The doctor billed a 99223. Based on what was documented I cannot even come up with a low level inpatient visit. What level should this be? If a patient is unable to cooperate and answer questions for the HPI and ROS or refuses, can you code a visit higher or do you have to code as is documented?
Jodi Dibble, CPC
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