A 64-year-old woman with a history of heart failure with reduced ejection fraction (HFrEF) was admitted to the hospital with decompensated heart failure one day ago. On day two, the patient is still short of breath and now develops a temperature of 100.9 degrees F. You order blood cultures, urinalysis (UA), and a chest X-ray. You review the UA and personally review the chest X-ray with findings documented that reveal left lower lobe pneumonia. Complete blood count and basic metabolic panels from the same day are also reviewed. The patient’s oxygen saturation is 92% on room air.
You start intravenous ceftriaxone and oral azithromycin and decide against monitoring for toxicity in this patient.
Q: What level of billing does this qualify for?
A: This would qualify for level 2 (99232) billing. She would qualify for acute illness with systemic symptoms by virtue of having pneumonia (moderate level in the complexity of the problem addressed) and prescription drug therapy (moderate level for risk of complication). Even though her complexity of data reviewed is high (for reviewing three unique tests and independently reviewing a chest X-ray), she achieves a moderate level of medical decision making in two out of three elements.
Always look at the “medical decision making” table when billing. A straightforward pneumonia without respiratory failure or sepsis is an “acute illness with systemic symptoms” and qualifies for a moderate level of medical complexity. A chest X-ray is a common test that can be independently interpreted and documented by the clinician to count as a category for the complexity of data to be reviewed.
Dr. Mehta is the medical director and an assistant professor of medicine at the University of Cincinnati Medical Center in Cincinnati.