General Surgery Coding Alert

Question: A surgeon in our practice admitted a patient to the hospital for initial observation status for suspected compartment syndrome. The next day, a different surgeon in our practice rounded and evaluated the patient and discharged the patient out of observation. How should I code this?

Codify Subscriber

Answer: You should bill the initial observation care using the appropriate code from the range 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: ...) depending on the complexity of the E/M visit.

While CPT^® is silent about subsequent observation and discharge services on the same date of service, you cannot bill an initial observation/hospital visit and discharge separately when they occur on the same date of service. So, it makes sense that the intent is to bill only for discharge if it is on a separate date of service than the admission, whether by another physician or the same physician.

You should bill the discharge as 99217 (Observation care discharge day management ...). The discharge code includes the following services:

• Final examination of the patient;
• Discussion of the hospital stay;
• Instructions for continuing care; and
• Preparation of discharge records.

If the other surgeon in your practice documents these items, then that surgeon should bill the discharge only for the second day.