A 46-year-old woman is admitted to the hospital with an exacerbation of chronic obstructive pulmonary disease (COPD) requiring intensification of her inhaler regimen, initiation of corticosteroids, and initiation of 4 L/min oxygen support via nasal cannula. She does not require oxygen at baseline and has a history of diabetes mellitus for which she takes metformin and glipizide. On day two, her blood sugar is noted to be consistently above 300 mg/dL since admission and requires the initiation of weight-based basal-bolus insulin along with frequent glucose checks.
What level of billing does this qualify for?
This would qualify for level 3 (99233). This patient has respiratory failure due to an exacerbation of COPD. This would be considered evidence of a severe exacerbation of an underlying chronic condition and, if documented as such, would meet the criteria for a high-complexity medical problem. The patient’s elevated blood sugar requiring the initiation of basal-bolus insulin is likely secondary to the initiation of steroids and even in the absence of hyperglycemia, increased vigilance is warranted. Thus, this could be documented as drug therapy requiring intensive monitoring for toxicity. The drug is corticosteroids (regardless of route, enteral or parenteral) and the toxicity requiring specific laboratory monitoring is severe hyperglycemia.
Tip
Patients with an acutely decompensated chronic medical condition or acute threat to life will often meet the criteria for level 3 billing (99223) if you are performing increased monitoring for toxicity. Common medications that would meet this criterion include diuretics, anticoagulants, antiarrhythmics, extended IV electrolyte replacement, and antibiotics (especially those requiring level monitoring such as vancomycin).
Dr. Gentile is an internal medicine hospitalist, section chief for acute care medicine, associate program director for internal medicine at Corewell Health Western Michigan, and assistant professor in the department of medicine at Michigan State University College of Human Medicine, all in Grand Rapids, Mich.
