tci E/M Coding Alert - 2019 Issue 6

You Be the Coder: Keep Track of Time, Report Observation Care Correctly

Question: Since 99234-99236 require at least eight hours in observation, do we need to track the time and document it, or do we just need to document the three key elements? Illinois Subscriber Answer: Yes, you should, because chances are that, eventually, you’ll be asked for documentation of the time. A recent CMS report indicates that Comprehensive Error Rate Testing (CERT) reviewers looked at Medicare claims for 99234 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires 3 key components: a detailed or comprehensive...

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