Neurosurgery Coding Alert

Question: Our neurosurgeon met a patient at the hospital and performed a  level-two observation service. However, the service did not occur in the facility's observation area. Notes also seem to indicate a separate evaluation and management service. Can we still report an observation code despite the setting, and can we code separately for the E/M service?

Texas Subscriber
 
Answer: Location is not the most important factor when deciding whether to use an observation code. The patient does not have to be in a designated observation unit for you to use the codes. Remember that observation is a status, not a location where the service occurs.

So if your physician provided a level-two observation with same-day discharge service outside the observation unit, you would report 99235 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these three components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity).

As for the E/M, you are not allowed to report an E/M with observation care for the same encounter on the same date of service. CPT instructs coders to roll the work of the earlier E/M service into the observation code.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.