1. E/M Service Code Selection:
On day two, the urologist provided an evaluation and management (E/M) service for a hospitalized patient with a low level for the number and complexity of problems addressed, minimal complexity for data reviewed, and moderate risk of complications.
CPT® Code 99232 is for a subsequent hospital care E/M service with a level of "Expanded Problem Focused" history and examination, with Medical Decision Making (MDM) of Moderate complexity. This matches the description provided, as the MDM includes a low number of problems, minimal data, and moderate risk.
2. Rationale for Excluding Other Options:
Code 99233 is for a subsequent hospital care visit with high complexity MDM (e.g., addressing a high number of problems or higher levels of data review), which does not align with the moderate risk described here.
Code 99221 is for initial hospital care, not a subsequent visit.
Code 99231 represents a lower level of subsequent hospital care with straightforward or low complexity MDM, which does not meet the moderate risk criteria in this scenario.
3. AAPC and CPT® Coding Guidelines:
AAPC and CPT® guidelines indicate 99232 as appropriate for subsequent hospital visits with moderate MDM, such as this visit with moderate risk but minimal data complexity.
Therefore, the correct answer is B. 99232.
