HOSPITAL CHARGE SHEET
PATIENT: Carson, Cason
AGE: 10
DATE OF ADMISSION: 01/02/2014
DIAGNOSIS: Coccidiomycosis Meningitis
DATE OF DISCHARGE: 01/08/2014
The patient was admitted on 01/02/2014 complaining of a severe headache and hyperpyrexia. An lumbar puncture determined on 01/02/2014 that the patient was suffering from coccidiomycosis meningitis. The patient was administered antibiotics and admitted to the hospital for observation and management of the condition. The patient’s condition improved slowly with a regression on 01/05/2014, at which time the antibiotics were changed. After the change in medication, the patient’s condition rapidly improved and by 01/07/2014, the patient no longer developed a fever or headache when not on pain medications. On 01/08/2012, the physician spent 20 minutes managing patient discharge, with instructions to continue antibiotics and pain medications, as needed.
What E&M service codes would be reported for this service?
Explanation
Answer: D - The E&M service codes that would be reported for this service are: 99222 (Initial Hospital Care Admission). This code only needs to be reported once per admission. The next code would be 99232 (X3) (Hospital Stay). This code is used to report daily visits by the hospital physician. In this case, the hospital stay would be reported as three units to represent the three days (an extended amount of time) that the physician spent caring for the patient. The next code would be 99231 (Inpatient Stay). This code would be reported as two units to represent the last two days before discharge, at a less complicated level of care, in response to an improved patient condition. The last code would be 99238 (Discharge). This code would be used to report the time it took to discharge the patient, which in this case, took less than 30 minutes.
