Answer and Analysis

You see a patient admitted earlier in the week with severe progression of Lewy body dementia. The family has decided to shift the focus of care from therapeutic to comfort measures. You make the patient CMO and consult palliative care. You spend a total of 40 minutes before, during and after the visit on the date of the encounter.

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 required for the visit. 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 problems addressed (severe exacerbation of a chronic illness) and the risk (de-escalation of care due to poor prognosis). High complexity MDM points us toward the 99233 level of care, which is the correct code for this encounter.