tci ED Coding & Reimbursement Alert - 2014 Issue 6

You Be the Coder: Discharging Patients After Overnight Observation Stays

Question: A patient presents in the ED with unspecified chest pain. After a complete work-up, the physician can't be sure whether the patient is having a heart attack. He decides to place the patient in observation care to determine if the patient needs admission. The physician observes the patient for 18 hours beginning at 1 p.m. on day 1, and discharges her after a normal stress test at 7 a.m. on day 2. What code(s) should I report?  North Carolina Subscriber Answer: You would report a pair of CPT® codes for this visit; one for the...

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