Wiki Observation transfer to Inpatient status

[Ellen]

Hello:

We seem to have a mis-communication in my coding department on History and Physical requirements. Can we use the Observation History and Physical when the patient is in observation for two days and then is admitted to a inpatient status. I have been researching this online and cannot seem to find clear guidelines or requirements on this any help would be greatly appreciated.

 

[Highlyfavored]

Hello:

We seem to have a mis-communication in my coding department on History and Physical requirements. Can we use the Observation History and Physical when the patient is in observation for two days and then is admitted to a inpatient status. I have been researching this online and cannot seem to find clear guidelines or requirements on this any help would be greatly appreciated.

Good Afternoon,
The observation H&P codes (99218-99220)can be use when the patient is in observation as long as your physician is the one admitting the patient to observation. 99224-99226 for observation subs. If the patient stay turns into inpatient, you would then use the inpatient subs codes(99231-99233) for the remainder of the time.

 

[Daniel Rowden]

If you are talking about the documentation requirement (and not the codes) then the physician would only need to do a new and updated History and Physical if the reason for the admission to inpatient is not the same as the admission to observation. If the occasion for the admission to inpatient is the same as the observation (just needs a higher level of care) I do not believe that a new one would be needed just an addendum of any changes.



Daniel Rowden CCS, CPC-H