99233 CPT Code, Level 3 Hospital Followup Note -Dummies.

A level 3 hospital subsequent care note is assigned to the code 99233.The highest level of non-critical care daily progress note is 99233.Understanding the documentation required is even more important when it comes to 99233 documentation.For 99233, the RVU is higher than for 99232.

You would be surprised to know how little writing is required to make sure all the key criteria are met.Common sense should prevail over trying to game a system with documentation.

The code 99233 is not appropriate if a patient is improving or stable.Sometimes, rounds are made on patients where it is essentially a continue meds, continue monitoring, improving basis, and a courtesy visit.These aren't meant to be 99233's.

The day after a patient is admitted, many management decisions continue to evolve and treatment changes are made.Specific medication adjustment and tests that need to be reviewed are required for blood pressure control and heart failure.It would require holding meds, getting tests, following them, and possibly arranging consultation and discussing with specialists for the development ofrenal failure.This would be a 99233 type situation.If the patient improves to a state where they are improved and awaiting final stabilization for discharge, the code 99233 would be appropriate.

There is a high level of complexity in the admission of a patient with a diagnosis of congestive heart failure and known ischemic cardiomyopathy.

On the second day, the patient improved, their meds changed to PO, and no tests were planned.

From the prior day, the situation worsened as the day went on, with concern for cardiac output being low.

Cardiac function was worse than thought, IV diuresis was discussed with consultants, and dobutamine started on the floor.

The situation improves and the patient is likely to be discharged in the next few days.

Documentation and understanding of requirements is important since 99233 is likely to come under more scrutiny since it is higher levels of billing.If there is a high level of complexity in terms of the patient and situation, the documentation will take care of itself.It takes an investment of time to truly develop an understanding of where it can be applied when we take a deeper dive into the guidelines for documentation.The whole thing becomes simpler once that understanding is developed.A note is like a point system in that a certain number of points are required for certain categories.When it comes to documentation for those that understand how it works, that can be an advantage.

35 minutes of care can be found at the patient bedside or on the floor of the unit.

If 35 minutes was spent with a patient, the time alone may justify the 99233.Over half of the time was spent on counseling and coordinating specifics of care.

There are 4 HPI elements.There are 3 chronic problems.

There was chest pain last night, left chest, radiates to neck, sharp, and intermittent in nature.

Shortness of breath was noted last night, intermittent and occurring at rest, no relation to exertion, chest pain, nausea, or diaphoresis.

The examples contain more elements than the HPI element.If a patient has a worsening of their condition and is described correctly, this should be easy to fulfill.

If there isn't a 4 point interval HPI, documentation of the status of 3 chronic medical conditions and 2 review of systems are acceptable surrogates for this.

Each point is given for the neck, lung, heart, abdomen, liver, digits, mental status, and so on.

We have 9 different systems which fulfill the 6 suggested, and we have 15 bullets which exceeds the required 12.

Acute or chronic illness poses a threat to life or organ system.

There is a template for 99233.I disagree with the idea that it takes a lot of time.Multiple pertinent and often ignored elements will be reviewed and taken in to account and can influence decision making if these elements are reviewed.If auto-population is used and you are familiar with the patient, the documentation is comprehensive and not very time consuming.The documentation criteria for a 99233 will be more fulfilled if a significant portion of these elements is followed.When you feel comfortable trimming the note to fit your needs, I would suggest starting comprehensive like this.

If there is a new issue, state here and describe with 4 points and symptoms.

Shortness of breath worsened overnight, causing to wake from sleep, worse with exertion and lying flat, no more chest pain, nausea or diaphoresis.

AKI is Interval development of respiratory distress.If congestive heart failure exacerbation is likely, will order echocardiogram to assess LV function, IV Lasix will hold ACE inhibitor in the setting of AKI, and continue other meds as stated.

Continue aspirin and Plavix, hold ACE due to AKI, check echocardiogram to assess LV function, after 4 days of NSTEMI.

Atrial fibrillation is rate controlled and continues with Coumadin for anticoagulation.Will talk to the pharmacy.

It would take some people a long time to do that, but others could do it quickly.If there is a higher level of care such as a 99233, the time and documentation should reflect that.It can be done in a way that is efficient.

There is more documentation that is needed.The note scores top points in every requirement, and only 2 out of 3 are needed.

Shortness of breath worsened overnight, causing to wake from sleep, worse with exertion and lying flat, no more chest pain, nausea or diaphoresis.

The 4 points required have already been hit.Only one of the other two categories (physical exam and complex decision making) is needed now.

Documentation of the status of 3 chronic medical conditions and 2 review of systems are acceptable surrogates if there isn't a 4 point interval HPI.

The data point section of medical decision making is influenced by the review of the labs.4 data points are needed.The increase in creatinine supports the AKI as a new critical diagnosis.A new significant problem with additional work up planned already qualifies for high risk.

The test is 2 points.If we had decided to review old records and summarized they would have been 2 points.An echo is a further point.We had already looked at the lab above.There are 6 data points that exceed the 4 required for the 99233.That is a requirement of the complex medical decision making out the way.It has to be at least 2 out of the 4 problem points, 4 data points and high risk.In theory, this note qualifies for a 99233 because we already have evidence for the new significant diagnosis.

Cardiac exam, irregular rhythm, no murmurs, and normal apical pulsation.

There are 12 bullets needed.At least 6 organ systems.Can be at least 2 bullets.There are three vital signs and a general appearance.We have a total of 14 points in the exam and we have 6 organ systems.

There is an established problem and a new problem threatening issue with further work up planned.

There is a new problem, threatening issues and further work is planned.

The documentation here is worth 12 problem points, we only need 4 and the acute AKI would suffice.

AKI is Interval development of respiratory distress.If congestive heart failure exacerbation is likely, will order echocardiogram to assess LV function, IV Lasix will hold ACE inhibitor in the setting of AKI, and continue other meds as stated.

Continue aspirin and Plavix, hold ACE due to AKI, check echocardiogram to assess LV function, after 4 days of NSTEMI.

Atrial fibrillation is rate controlled and continues with Coumadin for anticoagulation.Will talk to the pharmacy.

We have strengthened our documentation in the section above.The problems that are new and threatening have been laid out.The management of chronic issues has been reported.We documented the tests that were planned and the discussions that took place.

A supporting factor for complexity is the discussion with the other physicians and the family.The review of the medical can be used as a point in the data.The old echo review can be used as a point in data.

The ordering of the new echo is a data point.The entire criteria for high risk would have been fulfilled if this had been aCT angiogram, cath, or other contrasted cardiac scans.IV pain meds that are controlled would act as high risk if there was IV parenteral therapy.The Coumadin's high risk for toxicity and need for monitoring can make it a high-risk feature.

I don't like the idea of minimalist notes, they can breed complacency and not help with the thought process.We can still achieve what we need with a minimal note if we stick to the criteria for 99233.

Shortness of breath worsened overnight, PND, worse with exertion and lying flat, no chest pain, nausea or diaphoresis.

Alert and oriented, anxious, mildly increased WOB, JVP 10 cm, carotid normal, irregular rhythm, no heart murmurs noted.

We have 2 of the 3 main sections with all criteria fulfilled, interval HPI has 4 points and the physical exam has 12 bullets with 6 systems.Knowledge of what is required can allow focus on the main issues.The note will continue to be thought about.

Only one of the above points would suffice for the medical decision making high complexity requirement.The need for monitoring shows a high risk.If you take out the physical exam section, you can still fulfill 1/3 of the requirements.

The note was very short, but still way over the requirement in terms of points needed, which made it easy to fulfill the documentation needs for a 99233.

Shortness of breath worsened overnight, PND, worse with exertion and lying flat, no chest pain, nausea or diaphoresis.

4 data points can be; EKG did not review any significant changes.The concern for pulmonary edema was discussed.It was elevated to 1.6 points.The pharmacy will discuss with them the dose and monitoring of Coumadin, which is a high risk drug.