Inpatient Facility Coding & Compliance Alert

Question: The pulmonologist admits a 55-year-old patient with mild chronic bronchitis under observation care for treatment, and discharges him the next day. How do I code this?

Idaho Subscriber

Answer: Depending on the history, exam, and medical decision making (HEM) the pulmonologist documents, you may use one of three codes: 

• 99218 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity...) 

• 99219 (...moderate complexity…) or 

• 99220 (…high complexity...).

In the above situation, you will report 99218, 99219, or 99220 for the first day and 99217 (Observation care discharge day management…) for the following day. You can use 99217 for services on the day of discharge, but not if the observation and discharge are on the same date.