Coding: Your Top Coding Concerns Solved
Getting observation coding right; Coding for prolonged visits
By Bill Dacey For physicians who infrequently admit patients for observation, it’s worth going over the rules associated with these services. There are code combinations that, although technically permissible, are not completely in compliance.
A well-known rule associated with both observation and hospital inpatient admission is that all related E&M services billed on the day of the admission are included in the admit code if the same provider performs them. That applies to inpatient observation services as well. For example, if a patient visits your office complaining of chest pain and you send him for observation, test him further, and then admit him, you can factor services rendered in your office and in observation into the admit code you choose.
This rule stands even if someone else in your practice with the same specialty and group or tax ID number provided the office services.
But what if you admit a patient for observation at, say, 10 p.m., and the next morning admit him as an inpatient following test results? Can you bill both the observation admit and the hospital admit? After all, they are on different days.
Well, you can, but you need to have separate notes that include the documentation requirements for both codes, namely, a comprehensive history and exam and decision-making of a certain complexity. It is unlikely that anyone would repeat much of that work within a 12-hour period, and the second visit would be better billed as a hospital follow-up day. Continued...
