Wiki Observation Discharge note only

[kmschwarz]

In our practice, when the doctor places a patient in observation status, they are only charting the discharge. We do have electronic documentation in the hospital record of the admission, but no written documentation supporting the reason the patient was admitted to observation. The question is - can we bill just the observation discharge E/M code? Or, does an initial observation care E/M code have to be billed first?

 

[rthames052006]

So when your docs write the order for observation are they not seeing the patient prior to making that determination? The provider who initiates obs should be seeing the patient? Why would they not perform and bill initial obs care.

First thing you should do is educate your providers using the CPT book.

 

[kmschwarz]

We are a diagnostic radiology practice, but have a handful of Interventional Radiologists. When they do a "simple" procedure (ex: liver core biopsy), and then the patient develops a complication (n/v, pain, etc), the patient is placed in observation. The IR doc is only putting one handwritten note in the hospital record on the date of discharge, saying that it is for "observation services". We have had a lot of issues with getting them to document correctly, so just trying to figure out if we need to get them to make 2 separate notes - one for obs admit and one for obs discharge.

 

[MnTwins29]

Admitting privileges?

Do the IR docs document the order to place the patient in observation or is the actual order submitted by another hospital doctor, such as the hospitalist? That would make a difference.

Also keep in mind if the patient is admitted and discharged from observation on the same calendar date, there would be only one CPT code used (99234-99236) and only one note would be needed.

 

[kmschwarz]

yes, the IR doc does document the order to place the patient in observation. Usually, they do the procedure, then if there is a complication they admit patient to observation, then discharge the next day.

Everything I've read from CMS and other sites say you have to have 2 separate notes if you admit and discharge on the same day, so it is probably the same for different days as well.