Primary Care Coding Alert

Many factors affect coding when patients are admitted to the hospital for observation. Coders must know when patients were admitted to observation status, whether or not they were discharged on the same date, and if they were admitted to the hospital or another healthcare facility upon their discharge.

In addition, family practice coders should familiarize themselves with coding guidelines that affect observation status. Observation codes, like other evaluation and management (E/M) codes, may be assigned on multiple levels, and the rules about other E/M and admission codes may be paired with them.

Family physicians admit patients to observation in a wide range of scenarios, says Debra Wiggs, CMPE, chief executive officer of Community Physicians Administrative Support Services, (ComPASS, LCC), a billing and collections firm that provides support to 45 primary-care practices in Washington.

Typical situations where admission for observation may be necessary include geriatric patients experiencing symptoms of a serious medical condition like a stroke, pediatric patients presenting with an extremely high but unexplained fever, or individuals who have undergone some type of trauma like a head injury with loss of consciousness, she says.

Admitting and Discharging From Observation on the Same Day

In many cases, a patient may be admitted to observation and discharged that same date. For example, at about noon on the third day of a record-breaking heat wave, a 35-year-old male construction worker is seen after he collapses at the work site. After diagnosing dehydration (276.5, disorders of fluid, electrolyte, and acid-base balance; volume depletion), the physician admits the man to observation to monitor his condition while he receives fluids intravenously. Six hours later, he is released.

In a situation like this, where the patient has been admitted for observation and discharged on the same day, coders will choose a code from the 99234-99236 series (observation or inpatient care services [including admission and discharge services]), says Kathy Pride, CPC, CCS-P, coding specialist for Martin Memorial Medical Group, a practice with 57 primary-care physicians located in Stuart, Fla. These codes are used to describe the initiation of observation status, supervision of a care plan and performance of periodic assessments, as well as routine discharge services like final examination and instruction of continuing care.

When assigning codes from this E/M series, it is not necessary that the patient be located in a specifically designated observation area (i.e., as a separate unit in the hospital), she says.

Unless there were additional symptoms or related complications, it is likely the dehydration case described above would be assigned the lowest level of care, 99234. If, on the other hand, a patient presents with symptoms that indicate conditions like a cardiac event or neurological disorder, the higher level codes may [...]