Otolaryngology Coding Alert

Question: The otolaryngologist meets an established patient at the hospital with symptoms of dehydration at 9 p.m. Thursday. The provider orders observation care and the hospital places the patient in an outpatient observation bed. During that time, the physician documents an extended history of present illness (HPI), detailed review of systems (ROS), and a complete past/family/social history. The notes also indicate a comprehensive examination of eight organ systems. Medical decision making is of low complexity. After receiving several rounds of oral fluids, the otolaryngologist discharges the patient at 4 a.m. Friday. How should I report this encounter?

Tennessee Subscriber

Answer: Since the observation care lasted two calendar days, you should report a pair of observation codes. On the claim, report 99218 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity) for the first day of observation and 99217 (Observation care discharge day management) for the second day of observation.

Reasoning: The first day of care represents services that line up with 99218. For 99217, if the patient comes in as observation care on one calendar date and is discharged the following day, the physician may be able to report 99217 for the second date.

Keep in mind, however, that 99217 requires evidence of a face-to-face encounter between provider and patient.  

Without a face-to-face visit on the discharge date, you’ll probably have to leave 99217 off the claim.

Do this: Think of 99217 the same as an inpatient hospital discharge. The provider must document a discharge summary after seeing the patient and discharging them. The note for 99217 should look very similar to what one would see for a 99238 (Hospital discharge day management; 30 minutes or less).