Marcie Posted Mon 15th of April, 2013 23:16:12 PM
The patient is seen today. She has been transferred from the ICU to the floor. She has essentially stabilized. Again, she is having some type of seizure activity.
SuperCoder Answered Tue 16th of April, 2013 17:49:38 PM
Please provide additional details/more information is needed. For instance, does documentation show medical decision making?
Marcie Posted Tue 16th of April, 2013 17:54:34 PM
Her vitals overall are fairly well stabilized. Her postoperative dressings are in place. She did have a significantly elevated INR so the dressings have been kept in place to minimize the risk of bleeding. She was sleeping when I saw her so I did not wake her. Her toes are pink and warm. Calves are soft.
IMPRESSION: Seizure, status post left hip bipolar hemiarthroplasty.
SuperCoder Answered Wed 17th of April, 2013 05:56:54 AM
From this documentation, there is no trace of "seizure activity" as current condition. This is to be coded as 99231-99233 based on documentation level. As per CPT, for 99231, the required level of documentation is -->
Hx - PF / EPF interval
PE - PF
MDM - SF/Low
From the documentation above, it looks like that the Pt. is doing good on floor, and physician did not perform anything extensive. This will take the level to 99231 at max. But you need to decide the level of code based on overall E/M documentation.
The same question's answer had been provided last week in another thread posted by you, at: http://www.supercoder.com/my-ask-an-expert/topic/icu#post-22408