tci E/M Coding Alert - 2016 Issue 3

Reader Question: Calendar, Not Clock, Drives Observation Code Choice

Question: If we admit a patient to observation at 11 p.m. on Thursday and then release him at 2 a.m. on Friday, how should we code the services? Do we report an admit and a discharge code? Answer: Yes, you should report both an admit and discharge code. On the claim, report the appropriate code from the 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: …) code set for the first day of observation. Then, report 99217 (Observation care discharge day management…) for...

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