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Clarification Hospital visit / internal medicine

SuperCoder Posted Wed 30th of April, 2014 07:04:10 AM

The patient was admitted for stabilization of glucose levels. He has long standing type 1 DM, COPD and hypertension. On the 4th day of hospitalization Dr. Green was called by the nurse reporting several elevated glucose readings. The patient has no complaints other than a slight headache. The doctor ducuments that the patient is progressing well with the exception of his diabetes. repeat glucose test.. adjust the insulin dosage and enters an order for Accu-checks to be performed every 4 hrs w/ repeat glucose in 8 hrs. Exam included: BP IS 140/90, heart-normal, lungs clear: diagnosis type 1DM,COPD & HYPERTENSION. I coded hospital visit 99221 and dx 250.03, 401.9, 496 .. Have I coded this correctly.

SuperCoder Answered Thu 01st of May, 2014 00:32:27 AM

Correct. Medicare resources indicate that the initial evaluation by an inpatient physician can be billed using the initial code 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity …). Note that a patient might have multiple initial evaluations in a single day, if multiple physicians from different specialties see her..

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