Neurosurgery Coding Alert

Question: Our surgeon treated a patient in the emergency department and admitted the patient to observation. He monitored the patient beginning in the later afternoon and then all night. The next day, a consulting physician admitted the patient to inpatient status. Should we code 99220 as well as 99217?

Iowa Subscriber

Answer: Technically, the patient's observation stay spans two calendar days, so you would use 99220 (Initial observation care) for the first day. For the second day, you could potentially report 99217 (Observation care discharge).
 
The services you provide for 99217 include a final exam, discussion of the observation stay, follow-up instructions, and documentation. If your physician provided these services, 99217 would apply. If the admitting physician provided all the care on the second day, however, 99217 would not apply.
 
Also, keep in mind that all the services for the admitting doctor are rolled into the 99221-99223 series of inpatient admission codes, and you'll want to be sure to report these services when necessary.

 - Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.