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julia9723

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Would someone please double check this history. I have audited about 7 charts and I have not agreed with his final e/m code on any of them. This is a Subsequent hospital care.

SUBJECTIVE: The patient says her dyspnea has improved. She still feels fatigued. Other than over the counter medication for her osteoarthritis that she gets from the herbal supplement store, she has not been on any new medications.

PHYSICAL EXAMINATION:

Vitals Signs: Her heart rate has been between 40 and 48, respiratory rate is 18, blood pressure is 167/67. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive. CARDIOVASCULAR: She is bradycardic. LUNGS: Her lungs are clear bilaterally. ABDOMEN: Her abdomen is nontender, nondistended. EXTREMITIES: No cyanosis, clubbing or edema\


Besides the Assessment and Plan, that is all the charting.

He is getting a 99232.
 
In my opinion, unless there is some type of complication documented elsewhere this does not qualify for 99232. That's just my thoughts...
 
julia9723 said:
Would someone please double check this history. I have audited about 7 charts and I have not agreed with his final e/m code on any of them. This is a Subsequent hospital care.

SUBJECTIVE: The patient says her dyspnea has improved. She still feels fatigued. Other than over the counter medication for her osteoarthritis that she gets from the herbal supplement store, she has not been on any new medications.

PHYSICAL EXAMINATION:

Vitals Signs: Her heart rate has been between 40 and 48, respiratory rate is 18, blood pressure is 167/67. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive. CARDIOVASCULAR: She is bradycardic. LUNGS: Her lungs are clear bilaterally. ABDOMEN: Her abdomen is nontender, nondistended. EXTREMITIES: No cyanosis, clubbing or edema\


Besides the Assessment and Plan, that is all the charting.

He is getting a 99232.
Click to expand...

Looks more like a 99231, stable improving.
 
agree with 99231

Even with the exam level being detailed' (a stretch at best) I can't see this beyond level 1 due to the improvement of the pt. Nature of presenting problem...
 
I have to agree with 99232, if there is a chief complaint

If there is no chief complaint it is not billable at all.

Otherwise this is subsequent care, 2 of 3 required, EPF history, EPF exam, Moderate MDM.

EPF history-1 HPI element and 1 ROS, that is covered
EPF exam- 6 bullets on 97 or 2 organ systems 95, that is covered both ways
Moderate MDM- who knows since it wasn't posted but we already met the requirements for a 99232 with history and exam.

Laura, CPC, CPMA, CEMC
 
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