A 99232 CPT code explanation, 99232 examples, 99232 example note, 99232 RVU amount, 99232 wRVU / work RVU amount and a 99232 template for EMR.
What is CPT Code 99232?
CPT code 99232 is assigned to a level 2 hospital subsequent care (follow up) note. 99232 is the intermediate and most commonly used level of non-critical care daily progress note. When it comes to 99232 documentation is critical, however understanding of the documentation required is even more critical. WorK RVU (wRVU) for cpt code 99232 is of course lower than that for 99233 and higher than that for 99231.
How many work RVU (wRVU) are given for a 99232?
A 99232 CPT code is associated with 1.39 work RVU’s also known as wRVU.
A 99232 = 1.39 wRVU
In general when is a 99232 code appropriate?
When it comes to coding, as always in the day and age of EMR, documentation is key. You would amazed to see just how little documentation is required to ensure all the key criteria. It is critical though that common sense should prevail, there is never anything to be gained from gaming the system with generic documentation.
If a patient is improving or remains stable CPT code 99232 is probably appropriate. If a patient has a new acute problem or worsening of an issue then a 99233 may be appropriate. Often, rounds are made on patients where it is essentially a continue medications and monitoring on an improving patient. These are classic 99232’s.
Often, in the days after a patient is admitted, although management decisions continue to evolve and treatment changes are made, the changes are minimal and the patient is improving. Such as titration of BP or CHF meds in an improving patient. This would be a classic 99232 CPT code type situation. If new issues arise however that you are primarily treating, such as development of renal failure or hypoxia, that require specific medication adjustment and ordering of tests that need to be reviewed 99233 CPT code may be more appropriate. As the patient improves and / or awaiting final stabilization for discharge, CPT code 99232 rather than 99233 would be appropriate.
Example of hospital days where CPT code 99232 may be appropriate as long as the documentation is correct
Admission – Patient with shortness of breath and chest pain, comorbidities present, diagnosed with congestive heart failure and known ischemic cardiomyopathy treated medically, IV meds given, complexity is high.
CPT code 99223
Day 2 – Patient improved, meds changed to PO, home meds restarted, no invasive tests planned, continuing to monitor.
CPT code 99232
Day 3 – Kidney function worsens, meds held and changed appropriately, concern for cardiac output being low, nephrology consulted, situation worsened from prior day.
CPT code 99233
Day 4 – Echo reviewed, cardiac function worse than thought, thinking about right heart cath, dobutamine started on floor, IV diuresis ongoing, discussed with consultants.
CPT code 99233
Day 5 – Situation improves, renal function stabilizes with inotropic support and renal recommendations, breathing improved, meds regimen stable, labs and CXR stable, patient likely to be discharged in next few days.
CPT code 99232
Documentation is critical when it comes to a 99232
I can’t say enough that even though this is the most common progress note, documentation is key. It may often be the case that there are new issues and the patient is sick with high complexity. In that case a 99233 may be more appropriate however many people simply write 99232 out of habit. Importantly, under coding is seen as serious an issue as over coding. Unfortunately notes are like a point system where a certain number of points are required for a certain number of categories. That can be advantageous however when it comes to efficiency in documentation for those that understand how it works.
The key Components of a 99232
To bill a 99233 you need at least 2 of the 3 key components.
Expanded and problem focused history
Expanded and problem focused examination
Moderate complexity decision making
See below for a more detailed breakdown of these categories
One may also:
Coordinating care with other providers
Counsel the patient and family
Alternatively a 99232 can be billed on the basis of time as described below.
Time based 99232
The 99232 represent what would typically be 25 minutes of care at the patient bedside.
If 25 minutes was spent with a patient, if there is specific documentation, it is felt that the time alone may justify the 99232. That documentation must include 1) Total time spent (>25mins) 2) Description of the counseling and care coordination 3) State the amount of time that was spent on face to face and also counseling and coordinating specifics of care.
Expanded and problem focused history
1-3 HPI elements (locations/severity/duration/associated symptoms etc.) and 1 review of systems point.
99232 Examples of interval history:
Chest pain (1) is stable, left chest (2), radiates to neck (3), mild (4). No dyspnea or cough (ROS 1).
Shortness of breath (1) improved after steroids no relation to exertion (2) and mild in nature (3). No chest pain (ROS 1)
These examples easily contain 1-3 elements required for the HPI element of the 99232. If a patient has a stable or improving condition and it is described appropriately this should be easily fulfilled.
Expanded and problem focused examination
6 bullet points from one or more organ systems
1 point includes 3 vital signs reviewed
1 point for general appearance
1 point each for Neck / lung / heart / carotids / abdomen / liver / edema / digits / skin / mental status / neuro etc.
In general I would say include a few organ systems regardless.
99232 examples of detailed exam:
In this cardiac strong exam we have 5 different ‘systems’, we have 9 bullets, this exceeds the required 6.
1 point for these 3 vital signs
BP 136/74, HR 68, 02sat 98% on air (1 point for the 3 vitals)
1 point for this general exam
Laying in bed, mild increase work of breathing
1 point for this mental status exam
Alert and oriented, can follow instruction
2 points for this cardiovascular exam
Regular rhythm, soft systolic murmur, no added sounds (auscultation of heart)
1+ bilateral pitting edema (exam of periphery cardiovascular)
1 point for this exam of neck
JVP 8cm, elevated, bed at 45 degrees
1 points for this respiratory exam
Lungs clear to auscultation bilaterally
2 points for this abdominal exam
Soft and non tender, No masses felt
Moderate complexity decision making
For a 99232 typically a combination (2 out of 3 needed) of 3 problem points, 3 data points, and documentation of moderate risk.
99232 high complexity decision making – 3 problem points
Minor problem points (maximum of 2) = 1 point
Established problem that is stable or demonstrates improvement =1 point
Established problem that worsens = 2 points
New problem with no further work up planned (max of 1) = 3 points
New problem, with additional work-up needed =4 points
99232 high complexity decision making – 3 Data Points
Review or order labs =1 point
Review or order imaging =1 point
Discuss test with performing physician =1 point
Independently review image / tracing / specimen =2 points
Decide to obtain old records =1 point
Review and summarize old records =2 points
99232 moderate complexity decision making -Demonstration of moderate Risk
Needs one of the following 3 elements
Presenting problems
Diagnostic procedures
Management options
Presenting problems
One or more chronic illness with mild exacerbation or progression.
Two or more chronic stable illnesses.
Diagnostic procedures
Stress tests
Endoscopy
Deep needle biopsy
Cardiovascular imaging studies, with contrast, with no identified risk factors
Obtain fluid from body cavity (LP, thoracentesis, etc.)
Management options
Minor surgery
Elective major surgery
Prescription drug management
IV fluids with additives
Closed treatment of fracture
Comprehensive templates for 99232
Presented is a comprehensive template for a 99232. People will argue that its overkill and takes a lot of time, however I disagree. If the stated elements are reviewed it clearly improves patient care, as often ignored elements will be reviewed. The documentation is comprehensive but in reality not overly time consuming in the era of EMR, particularly if auto-population is used and you are familiar with the patient. If a significant portion of these elements is followed you will much more than fulfill the documentation criteria for a 99232. For those learning the specifics of documentation I would suggest starting comprehensive like this then when you feel comfortable the note can be trimmed significantly and tailored to needs.
Interval HPI;
(Describe treating issue with 1-3 HPI points, and add at least 1 review of system point)
(if new significant problem consider 99233 and ensure fulfillment of documentation)
Lab review; (between this and tests, need only 3 data points)
(Pull in lab values if desired)
(Comment on any changes on the review)
Test Review; (between this and labs, need only 3 data points)
(Pull in radiology testing) New radiology tests include
(CXR reading and review) CXR was reviewed and demonstrated
(EKG 12 lead reading and review) 12 lead EKG was reviewed and demonstrated
(Telemetry review and comment) Telemetry was reviewed and demonstrated
Meds;
(Pull in meds if required)
Physical Exam; (remember need only 6 bullet points from the following)
(Pull in BP, HR, temp, 02sat)
(Laying in bed / sitting in chair / ambulating)
(Comfortable / uncomfortable / other comment)
(Alert and oriented, able to answer questions)
(JVP is not elevated, carotid exam normal)
(Regular rate and rhythm, no murmurs noted, no added heart sounds, normal apical pulsation)
(2+ radial pulses bilateral, 2+ femoral/tibial pulses bilaterally)
(no edema in the lower extremities)
(no clubbing or cyanosis)
(Lungs clear to auscultation bilaterally, respiratory effort normal)
(Abdomen soft and non tender, normal bowel sounds)
(No new rashes or ulceration noted)
Problems
(Problem list being actively managed)
(If significant new problems interval – work up ordered, treatment started consider 99233 and fulfill other criteria for that)
(Problem 1 – stable / treating, – management)
(Problem 2 – stable / treating, – management)
(Problem 3 – stable / treating, – management)
(Problem 4 – stable / treating, – management)
Comprehensive cardiology centered template example for 99232 – see below for a detailed breakdown and discussion
Interval HPI;
Chest pain has improved, still some intermittent instances of chest pain.
No shortness of breath, nausea or diaphoresis.
Lab review;
Labs reviewed
Troponin remained negative
Test Review;
CXR was reviewed and stable
12 lead EKG was reviewed and normal sinus rhythm at a rate of 70
Telemetry was reviewed and demonstrated sinus rhythm rate 80-110
Meds;
Medication list or can simply say was reviewed
Physical Exam;
BP 100/70, HR 90, temp 98.0, 92% 02sat on 4 liters
Alert and oriented and able to answer questions
Laying in bed
No increased work of breathing
JVP normal at 8cm at 45degrees, carotid upstroke normal
Cardiac exam, regular rhythm, no murmurs noted
2+ radial pulses bilateral
Lungs clear bilaterally, respiratory effort normal
Abdomen soft and non tender
Problems
Chest pain – stable, markers negative
Hypertension, chronic, controlled
Diabetes Mellitus, controlled
Smoker – nicotine patch
Ongoing Issues
Chest pain, central chest, atypical in nature, markers negative, echocardiogram pending, continue aspirin.
Hypertension – currently normotensive, continue calcium channel blocker
Diabetes Mellitus – controlled, basal bolus insulin, readings acceptable, pharmacy co-management
Smoking – counseled, nicotine patch placed
Detailed Breakdown of the 99232 note template and example.
The example above is a relatively extensive documentation, it would take some people a long time to do that and others could run through it relatively quickly. If methodically done, be in an efficient manner.
By no means is all the documentation above needed. The note basically scores top points in every requirement, and remember only 2 out of the 3 are needed.
Interval HPI
Chest pain has improved, still some intermittent instances of chest pain.
No shortness of breath, nausea or diaphoresis.
This has already hit the 1-3 HPI points required. There are 3 ROS points here, exceeding the 1 required. Theoretically only 1 of the other 2 categories (physical exam and moderate complexity decision making) is now needed.
Lab review;
Labs reviewed
Troponin remained negative
The review of the labs contribute a point to the data point section of the medical decision making section. Remember, 3 data points are needed as part of the 2 of 3 requirements for moderate complexity decision making. Remember, a new significant problem with additional work up planned fulfills 4 points and qualifies for high risk and so in that setting 99233 may be more appropriate.
Test Review;
CXR was reviewed and stable
12 lead EKG was reviewed and normal sinus rhythm at a rate of 70
Telemetry was reviewed and demonstrated sinus rhythm rate 80-110
Personally reviewing the radiology test CXR is 2 points. Independent review of the EKG is 2 points (If we had decided to review old records and summarized that would have been 2 points). Later we order an echo, that’s a further point. We had already reviewed the lab above, that’s a further point. In total here we have 6 data points that exceeds the 3 data points required for the 99232. That’s already one of the 2 requirements of the moderate medical decision making out the way. Remember it has to be 2 out of the 3 of: 3 problem points, 3 data points and moderate risk.
Physical Exam;
BP 100/70, HR 90, temp 98.0, 98% 02sat on 2 liters (1 point)
Alert and oriented and able to answer questions (1 point)
Laying in bed , No increased work of breathing (1 point)
JVP normal at 8cm at 45degrees, carotid upstroke normal (1point)
Cardiac exam, regular rhythm, no murmurs noted (1 point)
2+ radial pulses bilateral (1 point)
Lungs clear bilaterally, respiratory effort normal (1 point)
Abdomen soft and non tender (1 point)
Remember that a total of 6 bullets are needed. 3 vital signs are 1 point and general appearance is 1 point. In the exam above we have a total of 8 points, it easily fulfills requirements.
Problems
Chest pain – stable, markers negative (1 point)
Hypertension, chronic, controlled (1 point)
Diabetes Mellitus, controlled (1 point)
Smoker – nicotine patch (1 point)
These 4 stable points are ok as they are issues that significantly impact treatment.
Our documentation here is basically worth 3 problem points, remember we only need 3. 1 points each for the established chronic stable issues up to a maximum of 2. And 1 point for the new problem, chest pain that is improving.
Ongoing Issues
Chest pain, central chest, atypical in nature, markers negative, echocardiogram pending, continue aspirin.
Hypertension – currently normotensive, continue calcium channel blocker
Diabetes Mellitus – controlled, basal bolus insulin, readings acceptable, pharmacy co-management
Smoking – counseled, nicotine patch placed
In the section above we have simply bolstered our documentation above. We have laid out the problems and demonstrated the further work up planned. We have reported the management of the chronic issues. We have documented tests planned and discussions had.
Specifics (optional, but count as documentation points, I make a routine of documenting these)
Discussions: Discussed with patient who understands issues and daughter at bedside
Review: General medicine and PT note reviewed
Tests: Echo ordered and pending
Code: Remains Full Code
The discussion with the other physicians involved and also the discussion with the family is a supporting factor for complexity. The review of the medical and the PT notes can act as a point in data. The ordering of the new echo acts as a data point also.
Brief note example that fulfills the criteria for a 99232
I’m not a fan of minimalist notes, I think it can breed complacency and doesn’t help with the thought process. The following shows however that when sticking to the criteria for a 99232 we can still achieve what we need to with a minimal note.
Interval history
Chest pain has improved, still some intermittent chest pain.
No shortness of breath or dizziness.
2 interval HPI points, 2 ROS points. (Only need 1-3 HPI points and 1 ROS point)
Objective points
BP 100/70, HR 90, temp 98.0, 98% 02sat on 2 liters, Alert and oriented, Laying in bed , JVP normal at 8cm at 45degrees, carotid upstroke normal, Cardiac exam, regular rhythm, no murmurs noted , 2+ radial pulses bilateral, Lungs clear bilaterally, respiratory effort normal, Abdomen soft and non tender
Theoretically we could stop here, we have 2 of the 3 main sections with all criteria fulfilled, interval HPI has the necessary points and the physical exam has 8 bullets, remember only 6 needed. This highlights how knowledge of what’s required can allow focus on main issues if that is the aim. In reality the note will continue thought.
Assessement
Chest pain – stable, markers negative, EKG reviewed and no changes noted.
Hypertension, chronic, controlled
Diabetes Mellitus, controlled
Smoker – nicotine patch
Fulfilled the 3 problem points needed. The EKG and the lab review acts as data points for the moderate complexity decision making also. In theory this is all that’s needed, you could even take out the physical exam section and still have fulfilled 2/3 requirements as needed.
Plan
Chest pain – Markers negative, trend another set, echo pending.
HTN – continue calcium channel blocker for HTN.
Diabetes Mellitus – continue basal bolus insulin, pharmacy co-management.
Smoking –nicotine patch placed
This note was very short, but still way over the requirement in terms of points needed, essentially its point system dense and easily fulfills the documentation needs for a 99232.
Even briefer note example that fulfills the criteria for a 99232
Interval history
Chest pain has mostly improved.
No shortness of breath.
1 interval HPI point, 1 ROS. (1-3HPI needed, 1 ROS needed)
Objective points
Technically the exam isn’t required!
3 data points can be; EKG reviewed no significant ST-T changes (2 points). Cardiac markers reviewed and negative.
3 data points already, (remember now we only need either moderate complexity risk or 3 problem points to complete the 2 out of 3 aspects of moderate complexity decision making)
Plan
Chest pain – trend markers, order echo
Diabetes – controlled
HTN – controlled
(2 or more stable chronic illnesses is moderate risk, the other classic for the 99232 is one or more chronic illness, with mild exacerbation, progression, or side effects of treatment)
This note was very very short, but still easily met the requirement in terms of points needed, essentially its highly point system based and despite the brevity of the note fulfills the documentation needs for a 99232.