EM Coding Alert

Question: A 69-year-old male patient came into our office this week with a mild acute episode of transient loss of consciousness. One of the doctors in our office performs a detailed history and examination with a medical decision making of straightforward complexity. She later admits the patient for observation care and treatment by the neurosurgeon. The patient responds to treatment and the admitting doctor discharges the patient on the following day. What should I report for discharge?

Georgia Subscriber

Answer: You should report 99217 (Observation care discharge day management) for the discharge day. With the nature of this patient’s condition, the typical issues that come with his condition, and the decision-making, 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) is the code you should report for the initial day. Pointer: If admission and discharge occur on the same date, you would select a code from the 99234-99236 (Observation or inpatient hospital care, …).