Hospital Progress note for Patient Sam Smith
CC: Multi-system organ failure
INTERVAL HISTORY: Patient remains intubated and sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has worsened, but patient remains non-oliguric.
PHYSICAL EXAM: 96/60, 112, 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive bowel sounds. Extremities show moderate edema.
LABS: BUN 89, creatinine 2.6, HGB 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate.
- Hypoxic respiratory failure
- Community acquired pneumonia
- Septic shock
- Non-oliguric acute renal failure
- Continue NS at 75 cc/hr
- Decrease ZOSYN to 2.25 grams IV Q 6H
- Follow cultures
- Continue tube feeds
- Titrate LEVOPHED to maintain SBP > 90
- Usual labs ordered for tomorrow
Critical care time: 30 minutes and 1 second.
Signed: Dr. Batman
What would you code this as ?
99231 - Subsequent Hospital
99232 - Subsequent Hospital
99233 - Subsequent Hospital
99291 - Critical Care
If you chose Critical Care 99291 you are correct!!! Refer to your CPT book for explicit
use on Critical Care Services....
Correct Coding Chart for Critical Care Services
Less than 30 Minutes
Use appropriate E&M Code
99291 once ( x1)
99291 once (x1) and 99292 once (x1)
99291 once ( x1) and 99292 twice (x2)
99291 once ( x1) and 99292 three times (x3)
99291 once (x1) and 99292 four times (x4)
194 Minutes or longer
99291 and 99292 as appropriate