tci ED Coding & Reimbursement Alert - 2023 Issue Q1

Reader Questions: Use New Observation Rules for This Encounter

Question: Encounter notes indicate that on Feb. 2, 2023, the provider performed initial observation care for a patient that involved a comprehensive examination and history along with moderate-level medical decision making (MDM). Total encounter time was 48 minutes. How should I report this encounter? North Carolina Subscriber Answer: Since you’re coding in 2023 now, you will be using the new guidelines for reporting hospital observation services. That means when choosing a code, you don’t have to rely on documentation of the levels of exam or history. You will, however, focus on MDM and time — because unlike...

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