Internal Medicine Coding Alert

Question: At 11 p.m. Thursday, the internist admits an established patient to observation. The patient says a car had "bumped" her off the road while she was bicycle-riding earlier in the week. She did not feel she needed medical treatment at the time but called the internist when her condition worsened. The patient's chief complaints were headache, vertigo and pain in her ribs. The internist conducts and documents a level-two observation service. He orders a CT scan and a two-view unilateral rib x-ray. The tests show no hemorrhaging or broken bones. At 7:45 a.m. Friday, the physician re-evaluates the patient and discharges her. What observation code best represents this encounter?

Alaska Subscriber

Answer: Because the physician admitted and discharged the patient on different calendar dates, you should report 99219 for the observation, and another code for the discharge. On the claim, report the following:

• 99219 (Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the observation

• 99217 (Observation care discharge day management) for the observation discharge

• 780.4 (Dizziness and giddiness) linked to 99219 and 99217 to represent the patient's vertigo

• 784.0 (Headache) linked to 99219 and 99217 to represent the patient's headache

• 786.50 (Chest pain, unspecified) linked to 99219 and 99217 to represent the patient's rib pain

• E813.6 (Motor vehicle traffic accident involving collision with other vehicle; pedal cyclist) linked to 99219 and 99217 to represent the cause of the patient's injury.