tci E/M Coding Alert - 2015 Issue 3

Reader Question: Watch Your 99218-99220 Observation Coding

Question: How should I code for a 55-year-old patient with mild chronic bronchitis when he is admitted by his pulmonologist to observation care for treatment and the patient is discharged and goes home the next day? Massachusetts Subscriber Answer: Depending on the history, exam, and medical decision making (HEM) the pulmonologist documents, you will use 99218 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity ...), 99219 (...

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