EM Coding Alert

Question: How should I code for a 55-year-old patient with mild chronic bronchitis when he is admitted by his pulmonologist to observation care for treatment and the patient is discharged and goes home the next day?

Massachusetts Subscriber

Answer: Depending on the history, exam, and medical decision making (HEM) the pulmonologist documents, you will use 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 ...), 99219 (... A comprehensive history; A comprehensive examination; and medical decision making of moderate complexity…), or 99220 (…A comprehensive history; A comprehensive examination; and Medical decision making of high complexity...).

In the above situation, you will report 99218, 99219, or 99220 for the first day and 99217 (Observation care discharge day management) for the following day. You can use 99217 for services on the day of discharge, but not if the observation and discharge are on the same date. There is another set of codes for admission and discharge to observation on the same day: 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, … ).