Primary Care Coding Alert

Question: The FP meets a 46-year-old established female patient at the local hospital at 2 p.m. Wednesday; she has suffered syncope secondary to severe dehydration due to her influenza. The physician documents a comprehensive history, comprehensive exam, and medical decision making of moderate complexity. The physician and staff work to rehydrate the patient and provide her with anti-nausea medicine; she responds positively to both treatments. Blood work reveals she is adequately hydrated and her blood pressure is stable, so the patient is  sent home at 10:23 p.m. Wednesday. Is this an established outpatient visit or an observation E/M service? California Subscriber Answer: It depends on whether or not the patient was designated as "observation status." If so, report the following: 99235 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: a comprehensive [...]