Question: A 42-year-old patient reports to the ED early on Tuesday morning for evaluation of uncontrollable shaking in her extremities and severe pain in her neck. The EP admits the patient to observation at 7 a.m. and orders blood tests and a CT scan — however, the shaking continues to worsen. The EP consults with a neurologist, who recommends hospitalization. The neurologist then admits the patient to the hospital as an inpatient at 6:25 p.m. Tuesday for more examination. Notes indicate a comprehensive history and exam, along with moderate medical decision making. Should I code this as an observation, or some other E/M service?
Answer: The ED physician could use an initial observation code in this situation.
On the claim, report 99235 (Observation or initial hospital care, …) for the E/M with 781.0 (Abnormal involuntary movements) and 723.1 (Cervicalgia) appended to represent the patient’s symptoms. ED physicians do not admit patients to hospital inpatient status (though they can recommend hospitalization); the neurologist will code for those services.
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