Challenge Yourself... Coding Scenario

Consider this Hospital Note - What would you code???

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.

IMPRESSION

1. Hypoxic respiratory failure
2. Community acquired pneumonia
3. Septic shock
4. Non-oliguric acute renal failure
   
   

PLAN

1. Continue NS at 75 cc/hr
2. Decrease ZOSYN to 2.25 grams IV Q 6H
3. Follow cultures
4. Continue tube feeds
5. Titrate LEVOPHED to maintain SBP > 90
6. 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
30-74 Minutes	99291 once ( x1)
75-104 Minutes	99291 once (x1) and 99292 once (x1)
105-134 Minutes	99291 once ( x1) and 99292 twice (x2)
135-164 Minutes	99291 once ( x1) and 99292 three times (x3)
165-194 Minutes	99291 once (x1) and 99292 four times (x4)
194 Minutes or longer	99291 and 99292 as appropriate