Hi,
My name is Ellen Keylor and I am a Certified Professional Coder and a member of AAPC. I have a question on leveling of inpatient services.
When I audited an initial hospital admission record, (using 1995 guidelines) the physician chose CPT 99223, however I found that the documentation supports the following:
Detailed History (9 ROS)
Comprehensive Examination
Comprehensive Medical Decision Making
I think that the service should be coded as 99222, however my colleague feels that because the detailed history is in the furthest column to the left under 99221, that this is the code that must be chosen. Any guidance with this scenario?
Also, are there guidelines available for auditing the inpatient (actual selection) of the level of service after History, Exam and MDM have been chosen? I could not locate anything with Medicare or online. Inpatient services are a little more complicated than office or outpatient evaluation and management services. Your assistance would be greatly appreciated.
My name is Ellen Keylor and I am a Certified Professional Coder and a member of AAPC. I have a question on leveling of inpatient services.
When I audited an initial hospital admission record, (using 1995 guidelines) the physician chose CPT 99223, however I found that the documentation supports the following:
Detailed History (9 ROS)
Comprehensive Examination
Comprehensive Medical Decision Making
I think that the service should be coded as 99222, however my colleague feels that because the detailed history is in the furthest column to the left under 99221, that this is the code that must be chosen. Any guidance with this scenario?
Also, are there guidelines available for auditing the inpatient (actual selection) of the level of service after History, Exam and MDM have been chosen? I could not locate anything with Medicare or online. Inpatient services are a little more complicated than office or outpatient evaluation and management services. Your assistance would be greatly appreciated.
