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Case of the Week
Hospital Progress Note: ETOH Withdrawal
Test our E/M-Code-Sense AI! Copy the clinical note below and paste it directly into the free trial calculator to see the audit-proof code instantly.
Click to Reveal the Answer & Analysis
The Correct, Audit-Proof Code Is:
99233
Coding by MDM yields a High complexity score, driven entirely by Data and Risk. For a subsequent hospital visit, this corresponds to code 99233.
See How E/M-Code-Sense AI Solved This Case
Stop leaving money on the table. Watch how our new AI Auditor catches this massive discrepancy between time and MDM in seconds.
Step 1: Feed the AI
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ASelect Encounter: Subsequent Hospital Care
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BEnter Note: Paste the raw clinical text & time.
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CClick Analyze: Let the engine do the work.
Step 2: Get Instant Results
- ✓ Result is 99233 Level of Care
- ✓ AI verifies ICD-10 Medical Necessity
- ✓ CDI Alert flags the massive Time vs. MDM discrepancy.
- ✓ 1-click EHR Coding Rationale generation
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Detailed Manual Analysis
You must always select whichever method (Time vs. MDM) yields the higher level of service. In this case, billing by time would result in a massive revenue loss.
Time-Based Result: 99231
The total time spent was 25 minutes. This just barely meets the minimum threshold for a 99231, making it a very low-level encounter if coded by time.
MDM-Based Result: 99233
The overall MDM complexity was determined to be High. For a subsequent hospital visit, High MDM supports the highest possible level of care: 99233.
MDM Deep Dive: The "2 out of 3" Rule
To achieve a High score, you need two of the three components to hit the "High" level. Here, Data and Risk carry the chart.
Problems Addressed: Moderate
The patient has three improving/resolving conditions. This is safely mapped as multiple resolving conditions or a chronic illness with exacerbation that is responding to treatment (Moderate).
Data Reviewed: High
You ordered 3 unique tests (BMP, CK, CBC) which satisfies Category 1. You also discussed the case with Addiction Medicine, satisfying Category 3. Meeting 2 out of 3 Data Categories scores a High.
Risk of Complications: High
Managing a patient on IV Ativan (a parenteral controlled substance) and dosing Vivitrol (injectable) inherently qualifies as High Risk prescription management.
The "2 out of 3" Rule Confirms High MDM
Because both Data and Risk met the highest possible thresholds, the final MDM code is secured at High.
Data
HIGH
Risk
HIGH
(Middle Value)
Problems
MODERATE
The middle value is High, which becomes the final MDM level.
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