General Surgery Coding Alert

You Be the Coder:

Where Does 'Observation' Take Place?

Question: Our surgeon performed an observation service for a patient who was not in the observation area of the hospital. Does this mean I shouldn't report an observation code?

Texas Subscriber


Answer: Location is not the most important factor when deciding whether to use an observation E/M code (99234-99236). The patient does not have to be in a designated observation unit for you to report these codes.

In a nutshell: Observation is a status, not a location where the service occurs.
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