Sample report,
History-Patient doing good on pain control stand point.
Pain scale-3
ROS-Allergy
PE: respiratory, CVS, GI, Integumentary, VS
Plan-
Using morphine/Zofran
On dilaudid PCA with ketamine will plan to transition to percocet or oral analgesia
Laboratory results reviewed.

We have controversy whether to bill 99231 or 99232 because of use of opioids can we consider risk as High, table A and B constitutes me only 1 point each and led to code 99231. But can we code as 99232 consider use of opioids.
Any inputs.