Wiki Subsequent Hospital Care (99231 - 99233)

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MsDean1

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Hello,

When coding E/M for subsequent hospital care, if there is no history component or the history component lacks enough detail, can I drop it and still level it out using the exam and decision making since 2 out of 3 is required?
 
Per CPT, all levels of subsequent hospital care include reviewing... changes in patients status (i.e., changes in history...).

If there is no history component then the hospital care is incomplete, IMO.

Edited to say... frankly, it looks like sloppy documentation or just being lazy. You know the doctor looked at the history of the patient, they just didn't document anything.
 
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