Forum - Questions & Answers

Jul 6th, 2010 - Kathy 2 

subsequent hospital visits 99231-99233

The patient is a baby/child or on a vent and unable to communicate with the doctor. The mother of the child is not available to answer questions. The doctor does not document the patient is unable to communicate. When auditing this chart, how many elements do give credit for in the Review of Systems (ROS), 1, 2-9, or 10? Where do I find written documentation to support this decision?
Kathy

Jul 6th, 2010 - Codapedia Editor 1,399 

subsequent hospital visits

If the child is on a vent, wouldn't you be using the neonatal or pediatric critical care codes?

Jul 6th, 2010 - Kathy 2 

subsequent hospital visits

No, the child is not on a vent, these are two different charts. The codes are standard subsequent hospital visits, 99231-99233.

Jul 6th, 2010 -

Hey now

[If the child is on a vent, wouldn't you be using the neonatal or pediatric critical care codes?]


Editor: A patient can be on a vent and not critically ill. The critical care codes, at least for adults, require a critical situation, not a critical setting.

Jul 6th, 2010 - nmaguire   2,606 

E/m

The subsequent hospital visits require 2 of 3 key components. It is not necessary to document the ROS (which you have to review with someone or document why it was not done) The code assignment could be based on MDM and the physicial exam. documented.



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