Hi guys,
I am studying E/M right now, and it really is a challenging topic. I found a question in one of AAPC's published materials.
It says:
The physician was notified to go to the hospital floor for medical management of a 56 year old patient admitted one day ago for aspiration pneumonia and COPD. No chest pain at present, but still SOB and some swelling in his lower extremities. He was tachypenic yesterday; lungs reveal course crackles in both bases, right worse than left. He is continuing with intravenous antibiotic treatment and respiratory support, reviewed chest X-ray and labs. The patient is improving and a pulmonary consultation has been requested. What CPT code should be reported?
Here's the answer:
The physician is providing subsequent hospital care to an inpatient. The physician performed an expanded problem focused interval history (brief HPI, pertinent ROS since last assessment) + problem focused exam (1 system) + moderate MDM (uncertain prognosis [pulmonary consult], three data points and established diagnosis that is improving). Subsequent hospital codes require two out of three key components. The code documented is 99232.
1.) Are you guys able to determine the level of MDM based on the information provided in this question? I am looking at the MDM table in the CPT manual, and it really is very vague.
2.) When you guys determine the level of history, aren't you frustrated that counting the number of elements is not always straightforward? I have discussed the other E/M question with one of AAPC's instructors, and she agreed that the answer might not be entirely correct, and she would need to report the possible errors to the team (I never heard back from her).
If you guys do not look at the answer provided here, would you be able to figure out 99232 is the best answer?
Thanks.
I am studying E/M right now, and it really is a challenging topic. I found a question in one of AAPC's published materials.
It says:
The physician was notified to go to the hospital floor for medical management of a 56 year old patient admitted one day ago for aspiration pneumonia and COPD. No chest pain at present, but still SOB and some swelling in his lower extremities. He was tachypenic yesterday; lungs reveal course crackles in both bases, right worse than left. He is continuing with intravenous antibiotic treatment and respiratory support, reviewed chest X-ray and labs. The patient is improving and a pulmonary consultation has been requested. What CPT code should be reported?
Here's the answer:
The physician is providing subsequent hospital care to an inpatient. The physician performed an expanded problem focused interval history (brief HPI, pertinent ROS since last assessment) + problem focused exam (1 system) + moderate MDM (uncertain prognosis [pulmonary consult], three data points and established diagnosis that is improving). Subsequent hospital codes require two out of three key components. The code documented is 99232.
1.) Are you guys able to determine the level of MDM based on the information provided in this question? I am looking at the MDM table in the CPT manual, and it really is very vague.
2.) When you guys determine the level of history, aren't you frustrated that counting the number of elements is not always straightforward? I have discussed the other E/M question with one of AAPC's instructors, and she agreed that the answer might not be entirely correct, and she would need to report the possible errors to the team (I never heard back from her).
If you guys do not look at the answer provided here, would you be able to figure out 99232 is the best answer?
Thanks.