Coding Corner: A Critical Opportunity

A 17-year-old with a history of major depressive disorder who is new to the hospitalist service is being transferred out of the pediatric intensive care unit (PICU) after an intentional Benadryl overdose in a suicide attempt. You review her labs from this morning showing that her electrolytes are normal. You review her pregnancy test and urine drug screen which are both negative. You review the nursing note from this morning which states she is alert, oriented, and calm and her parents are at the bedside. You interpret her electrocardiogram (EKG) tracing and calculate her QTc to be back to normal at 420. She remains actively suicidal and will require transfer to an inpatient psychiatric facility following the hospitalization per your discussion over secure texting with the social worker. After discussing her management with the PICU physician over the phone, you accept the patient for transfer out of the PICU. What level of billing does this qualify for? This patient would qualify to be billed as an initial hospital care level 3 (99223). Although this patient has already been in the hospital for several days, because this patient is new to your service/group then you can bill for a history and physical (H&P) initial encounter. A full H&P must be documented, though billing depends only on the medical decision-making (MDM) or time so extensive documentation is not required, only what is medically indicated. The MDM is a level 3 as the patient has an acute problem with ...
Source: The Hospitalist - Category: Hospital Management Authors: Tags: Business of Medicine Clinical Guidelines Coding Source Type: research