Ob-Gyn Coding Alert

Question: A pregnant patient presents in the emergency department (ED) during her pregnancy complaining of abdominal pain, cramping, etc., and is transferred to labor and delivery for observation (where she is admitted and released on the same day). Can the physician bill for this, or is this visit considered part of the global service? Answer: Assuming the physician physically saw the patient in observation that day, you can bill for it using 99234-99236 (Observation or inpatient hospital care ... including admission and discharge on the same date ...). But keep in mind that the minimum documentation requirement for observation care is a detailed history and exam in addition to medical decision making of any level. If this is not in your ob-gyn's record (and it must be performed by the admitting physician), you cannot bill an observation code but would revert to an outpatient visit. Also remember that if your [...]