ED Coding and Reimbursement Alert

Question: Do we need to document a family history before assigning code 99220 or 99236 for comprehensive or high complexity observation services?  

Codify Subscriber

Answer: You are correct in that the CMS documentation guidelines say that comprehensive observation services, unlike ED E/M, require three of three past, family and social history elements for the highest level. Also, CPT^® includes these elements in the definition of a comprehensive history, which is required for observation codes.

• Chief complaint;
• Extended history of present illness;
• Review of systems that is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems;
• Complete past, family, and social history

Only the lowest level of observation, codes 99218 or 99234, can be billed with a detailed or comprehensive history and physical exam; but what usually drives the observation choice is the level of medical decision-making (low, moderate, or high).