Orthopedic Coding Alert

Question: How should I report an observation service that includes the following: On calendar day 1, the orthopedist admitted the patient to observation and performed a comprehensive history and examination, along with moderate medical decision making (MDM). On calendar day 2, the orthopedist decided that they were not ready to admit the patient to the hospital, but did want the patient to remain in observation. Early in the morning on calendar day 3, the orthopedist met with the patient face-to-face and then discharged him. How should I report this encounter?

Nebraska Subscriber

Answer: On the claim, you should report the following:

• 99219 (Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity …) for day 1.
• 99224 (Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity …) for day 2.
• 99217 (Observation care discharge day management) for day 3.

Caveat: Observation services that stretch into a third calendar day are pretty rare, and your payer might wonder why the patient wasn’t admitted or released sooner than day 3. To ward off any potential questions about the claim, consider included documentation explaining the patient’s condition and why the patient was in observation for three calendar days.