Pediatric Coding Alert

Question: A pediatrician admits a patient to observation on Feb. 22. The physician writes orders to change to full admission on Feb. 23. The patient remains in-house on Feb. 24, and the pediatrician discharges him on Feb. 25. Should I report day 1 as initial observation, days 2 and 3 as subsequent hospital care, and day 4 as discharge? Or should I bill all days as inpatient, including Feb. 22 as the initial hospital care?

Maryland Subscriber

Answer: The answer to both of your questions is "No."

You should stick with observation care (99218-99220, Initial observation care, per day, for the E/M of a patient ...) on Feb. 22 because the pediatrician admitted the patient to observation status and did not change the order in person that day. The physician must provide a face-to-face encounter on each day and satisfy the requirements for each individual service.

You would change to initial hospital care (99221-99223, Initial hospital care, per day, for the E/M of a patient ...) only if the pediatrician returned the same day -- on Feb. 22 -- and wrote a new order to admit the patient to inpatient status.

Although a patient in observation status has been at the hospital, you still code the first day of inpatient status as initial hospital care. While in observation care, the patient is an outpatient (place-of-service code 22, Outpatient hospital). Hospital admission makes him an inpatient (POS code 21, Inpatient hospital) for the first time.

You should report the claim as follows:

• initial observation care (99218-99220) on Feb. 22

• initial hospital care (99221-99223) on Feb. 23

• subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) on Feb. 24

• hospital discharge day management (99238-99239) on Feb. 25.