Capture ‘Patient Limbo’ Period With These Observation Coding Steps
Posted on 10. Mar, 2009 by Editor in Hot Coding Topics
Internist deciding on admission? That’s your signal to look at observation family.
You can quickly pin down which observation code (99218-99220 or 99234-99236) pair to use, and whether to add a discharge code (99217), if you zoom in on the stay’s date(s) and length.
Ensure your observation claims are 100 percent accurate simply by following this 5-step plan.
Step 1: Confirm Observation Service
Before coding, be sure that the service qualifies as an observation, confirms Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.
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Observation is a hospital-based outpatient service used to determine if a patient needs inpatient care. So when you’re reviewing the notes, ensure claim correctness by checking the encounter specifics against this observation definition.
Observation: The internist meets a patient at the hospital who is experiencing pain in his chest and left arm; the internist admits the patient to observation status to run tests and make sure the patient does not need inpatient care for cardiac issues.
Not an observation: A patient reports to the hospital in severe pulmonary distress. The internist conducts a brief exam and attempts to stabilize the patient, then speaks to the patient’s pulmonologist, who admits the patient to the intensive care unit (ICU) immediately to begin active treatment and patient care measures.
Step 2: Tally Observation Length
Next, you’ll need to revisit the encounter notes to see how many calendar days the observation service spanned. If the patient is in observation for more than one calendar day, you’ll choose from the 99218-99220 (Initial observation care, per day, for the evaluation and management of...
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