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Case of the Week
Prolonged Services & Advanced Dementia
Test our new E/M-Code-Sense AI! Copy the complex 80-minute clinical note below and paste it directly into our free trial of Code-Sense to see the audit-proof code instantly.
Click to Reveal the Answer & AI Analysis
The AI Calculated Code Is:
99233
Non-Medicare / CPT
+ 99418 x 2
Medicare / CMS
+ G0316 x 2
Not only did it nail the base code (99233), but the AI automatically identified and calculated the exact prolonged service increments for BOTH Medicare and Commercial payers!
Exact Code-Sense AI Output
Calculating prolonged services manually is tedious and highly audited. Watch how the AI engine perfectly dissected the exact clinical note you just read in under 3 seconds.
Result
99233 + Prolonged Services
E/M Service Code: 99233 + 99418 x 2 (or G0316 x 2 for Medicare) (Subsequent Hospital Care)
Prolonged Services Breakdown
Non-Medicare/CPT:
2 units of 99418
Medicare/CMS:
2 units of G0316
Basis for Code Selection
Both total time spent and overall MDM. Total time spent on the date of the encounter was 80 minutes. This exceeds the 50-minute threshold for 99233. The total time also qualifies for 2 units of prolonged services, as it exceeds the base threshold by 30 minutes Floor((80-50)/15) = 2. The level is also supported by High Medical Decision Making.
MDM Details Breakdown
- Problems Level: High — Severe exacerbation of chronic illness (Severe, progressive vascular dementia with associated inability to eat).
- Data Level: Moderate — Category 3 Met. Discussion of management with family/independent historian regarding prognosis, nutrition options, and palliative care. (Also qualifies for 1 point in Category 1 for assessment requiring an independent historian).
- Risk Level: High — Decision regarding de-escalation of care (Discussion of shifting focus from therapeutic to comfort measures).
Audit Risk Flags
None detected. Encounter type and documentation align.
Documentation Improvement (CDI)
None identified. Documentation supports the maximum justified level. Note: Only document this if the service was actually performed and medically necessary.
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Visual MDM Breakdown
The 2-out-of-3 rule confirms the High MDM, serving as secondary validation for the 99233 base code.
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