Wiki new coder needs help

[ggparker14]

I am trying to understand observation vs inpatient. I have a patient in observation, doctor examines and makes a decision for surgery. The doctor lists herself as the admitting physician. Can I have a obs E/M code with 57 and AI for admitting or if the doctor is saying she admitted the patient, should I use inpatient E/M code? The patient does have Medicare. Any help is appreciated. Thanks.

 

[Kris Cummings]

Unfortunately, observation and inpatient codes cannot be billed together. I would get a copy of the patient status sheet from the hospital to determine whether the patient remained in observation, or was actually admitted. That should resolve what category to select the code(s) from.

You should be able to call the hospital and through medical records, or admissions, obtain a copy of a patient status sheet for a particular date (or dates) of service.

Kris