Forum - Questions & Answers

Jul 22nd, 2010 - gfrazier

inpatient billing cpt 99231 - 99233

I have two new Attendings with Trauma/critical care surg. Both previous where at other hospitals as fellows..So they went from fellow to attending..in speaking with one she stated that she thought documenting ROS was only need in clinic setting.for example that documentation should be hx, ros, exam, and MDM but when it came to inpatient charting it ROS did not..in looking at the cpt, in order to bill cpt 99231 - 99233 at least 2 of the 3 key components needs to be documented. I told what you do must support the level of cpt and it has to be noted in your note.

Jul 22nd, 2010 - nmaguire   2,606 

subsequent hospital visits

You will see the "history" is an interval history. Codes 99231-99233 require documentation of the:
Interval history as either problem-focused, expanded problem-focused, or detailed;
There is no exception for hospital code requirements when it comes to Type of history documented and medically necessary. 2 of 3 key components must be documented unless billing on "time" alone. The ROS is not required for PF history.
Codapedia has an article on Interval History.



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