Subsequent hospital care includes a review of interval changes since last time, so don’t count on that as helping your MDM so much…….
But the good news is for subsequent care, just like for established patients, you only need 2 of 3 categories at the highest level to qualify your coding…..
Let’s look at the highest and go down from there
99233 requires:
1. A detailed interval history
2. A detailed examination
3. Medical Decision Making of High Complexity……
Remember, you only need 2 of 3.
A detailed interval history is the next to highest level of history. Which means, you should at least be doing this all the time…..It includes
A. A Chief Complaint
B. An extended HPI: 4 points (Location, Severity, Timing, Modifying Factors, Associated Symptoms, Duration, Quality, Context) All you need is 4 of these…..OR the status of 3 chronic or inactive problems
C. 2-9 Review of Systems, don’t we usually do 10?
The last requirement is dropped for subsequent hospital care.
Dropped a requirement? Seriously? Yes. But only for Subsequent Nursing facility care, Subsequent Inpatient care and Subsequent inpatient consultation……
So, it looks as if we can make the History requirement
Next Up, the physical exam
A Detailed Examination
This requires 12 bullets from ANY organ system. Or from multiple organ systems……
These include Vitals and General as 2 Bullets. So 10 bullets points…….You better know the systems by now!
You don’t? First time here? Look at this post for the physical exam
Constitutional
(1 bullet for three vital signs)
(1 bullet for general appearance)
Eyes
(1 bullet for inspection of conjunctivae and lids)
(1 bullet for examination of pupils and irises)
Ears, Nose, Mouth and Throat
(1 bullet for external inspection of ears and nose—“atraumautic”)
(1 bullet for examination of oropharynx)
Neck
(1 bullet for examination of neck)
(1 bullet for examination of the thyroid)
Respiratory
(1 bullet for auscultation of lungs)
(1 bullet for assessment of respiratory effort)
Cardiovascular
(1 bullet for auscultation of heart)
(1 bullet for examination of extremities for edema or varicosities)
Gastrointestinal
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
Lymphatic
(1 bullet for examination of lymph nodes in neck)
(1 bullet for examination of lymph nodes in extremities)
Skin
(1 bullet for inspection of skin and subcutaneous tissues)
(1 bullet for palpation of skin and subcutaneous tissues)
Psychiatric
(1 bullet for description of patient’s judgment and insight)
(1 bullet for brief assessment of mental status—orientation)
Total systems = 10
If, examine heart, lungs, skin, abdomen you meet the grade. If you examine HEENT and heart and lungs, you make the grade as well………
In essence, most of your subsequent care is 99233. What is a 99232?
But what if you didn’t make both of those? You fall back on Medical decision making of high complexity.
You need 2 of 3 criteria to make the high complexity grade. As always, these are divided into:
A. Problem Points, you need 4
B. Data Points, again you need 4
C. Risk, you need high risk
The good news, you only need 2 of three. Also, the decision to make someone DNR or to use IV controlled substances qualifies you for high risk!!!
Here’s to a morphine drip!!!
So think about it, really hard. Aren’t most of your patients in this realm? Do you do exams and review the history daily? If you are and aren’t billing a 99233, you are missing crucial dollars you deserve for your work!
