Question

The physician was called to the hospital floor for the medical management of a 56 year-old patient admitted one day ago with aspiration pneumonia and copd. no chest pain at present, but still sob and some swelling in his lower extremities. patient was tachypneic yesterday; lungs reveal course crackles in both bases, right worse than left. the physician writes instructions to continue with intravenous antibiotic treatment and respiratory support with ventilator management. he reviewed chest x-ray and labs. patient is improving and a pulmonary consultation has been requested. what cpt® code is reported?

Answer 1

99231 CPT code is reported.

In the CPT code 99231, all the observations starting from the first observation, to stable health condition, to recovering condition are documented.

In this case, the sequential events reported are as follows:

a) the old man was reported with pneumonia, chest pain along with crackling of lungs with right being worse than the left.

b) All these observations were documented by the physician

c) He further wrote the instructions to continue the intravenous antibiotic Treatment and respiratory support with ventilator management

d) Later, the physician reviewed the chest x-ray lab reports and found that patient condition is improving.

e) It was suggested by the physician that pulmonary consultation is required as the patient started improving

All these sequential events are majors of the CPT code 99231.