99232 when your best isn't good enough!

Sometimes we have patients who just don't meet 99233 criteria for additional days in the hospital. I often find myself asking "Why not discharge them?" Inevitably it is for silly things like

1. Needs IV abx
2. Awaiting placement
3. Has a ride tomorrow
4. Getting therapeutic (Although if there is a PE involved, you go to the 99233 line)

In these cases I find it necessary to review why we missed the 99233 and why I need to code as a 99232.....

For your edification.......

a 99232 is a subsequent day of care in the hospital Which needs you to meet 2 of 3 criteria.
The best part about this coding system is that when you have already established care with the patient, the criteria for upper level codes is far less....

In this case the 2 of 3 are

1. Expanded Problem Focused interval history
2. An expanded Problem Focused examination
3. MDM of moderate complexity

To compare to the 99233 you can read it here.
So again with the sub-categorization of what expanded problem focused means....

Exanded Problem Focused History is:
A chief complaint, a brief HPI (containing one to three HPI elements), plus one ROS. No PFSH is required.

Are you telling me you only do ONE ROS? And only one HPI element? If you do 3, you better do 4 elements. If you do one ROS, you really should do more........Why? It serves the patient better to look for things and think about the case. Too much of medicine is driven to mindless care......

Expanded Problem Focused Exam is:
6 bullet points from one or more system.
Heart and Lungs? Yup.....all done.....

Basically this is a gimme. Did you end up doing more than this? Then you should consider the 99233

Lastly you need to factor in Medical Decision Making.....and in this case it is of moderate complexity.....

What is Moderate Complexity? Remember, this category is judged by
1. Problem Points- I.E. what is the nature of the problem.
2. Data Points- I.E. what work did you review and cogitate over
3. Risk Level- I.E. risk to patient's life

Again, you only need 2 of 3 at the highest level

The risk is evaluated in a risk table presented best at EM University.

One chronic problem with mild exacerbation gives you moderate risk so do 2 stable controlled diseases i.e. hypertension and hyperlipidemia

So you can usually get 2 of 3 here pretty easily. But you should always ask yourself.......did I really do a 99233 instead of a 99232.....It is just good medicine.