Answer and Analysis
You see a patient you admitted yesterday with CHF. Patient continues to complain of SOB and is requiring supplemental oxygen. BP is 160/90. You decide to give 40 mg IV Lasix and order a repeat BMP for the a.m. to monitor electrolytes. Total time spent (seeing the patient, documenting the note, entering orders) is 40 minutes.
What is the correct level of care?
Correct Answer: 99233
For these encounters, the level of care may be selected based on time or based on the MDM. If coding based on time, this visit would only qualify for the 99232 level of care. This encounter requires high complexity MDM based on the problem addressed and the risk as outlined below. High complexity MDM points us toward the 99233 level of care, which is the correct code for this encounter.
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