Would this scenario be considered "New Problem with work-up" or without?
The provider admitted the patient from the ER and wants to charge a 99223.
His assessment is acute perforated diverticulitis (confirmed by CT scan). His plan is emergent exploratory laparotomy with possible bowel resection & possible colostomy. 99223 requires High MDM so this is what we've got:
Amt of Data: He reviewed labs and personally reviewed the CT scan (3 pts)
Table of Risk: Emergency major surgery (4pts)
# of Diags/Mgmt Options: Some coders consider the Exploratory Lap as work-up planned, others don't since the diag was known before the surgery and consider the exploratory lap as part of the treatment. (3 or 4 pts?)
I'd be grateful for any opinions! Thanks-Sue
The provider admitted the patient from the ER and wants to charge a 99223.
His assessment is acute perforated diverticulitis (confirmed by CT scan). His plan is emergent exploratory laparotomy with possible bowel resection & possible colostomy. 99223 requires High MDM so this is what we've got:
Amt of Data: He reviewed labs and personally reviewed the CT scan (3 pts)
Table of Risk: Emergency major surgery (4pts)
# of Diags/Mgmt Options: Some coders consider the Exploratory Lap as work-up planned, others don't since the diag was known before the surgery and consider the exploratory lap as part of the treatment. (3 or 4 pts?)
I'd be grateful for any opinions! Thanks-Sue