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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 Wed 30th of April, 2014 16:57:44 PM

It looks correct here.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.

Option: Because some evaluations may not meet the requirements for 99221, carriers shouldn’t find fault with those who use a "subsequent" code even if it’s the initial service (assuming the subsequent code better describes the level of service). In that case, you might be better served by reporting 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity …).

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