General Surgery Coding Alert

Question: A patient presented to the ED complaining of dizziness and nausea following a minor blow to the head. The surgeon examined the patient and, finding no definitive cause for the condition, placed the woman in observation at 9 a.m. At 7 that night, the surgeon decided to discharge the patient. Which observation code should I use?

Arkansas Subscriber

Answer: Because the surgeon admitted and discharged the patient on the same date, you should choose the appropriate code from the range 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...), based on the documentation provided.
 
In 2001, CMS indicated that facilities billing the same-day observation admit/discharge codes 99234-99236 for Medicare patients must document lengths of stays of at least eight hours. For stays of fewer than eight hours, use codes from the initial observation series 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient ...).