tci General Surgery Coding Alert - 2018 Issue 6

Reader Question: Focus on Observation Discharge

Question: A surgeon in our practice admitted a patient to the hospital for initial observation status for suspected compartment syndrome. The next day, a different surgeon in our practice rounded and evaluated the patient and discharged the patient out of observation. How should I code this? SuperCoder Subscriber Answer: You should bill the initial observation care using the appropriate code from the range 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: ...) depending on the complexity of the E/M visit. While CPT® is silent about subsequent observation...

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