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Neurology & Pain Management Coding Alert

READER QUESTIONS:

Choose Inpatient Code for Same-Day E/M

Published on Sun Aug 09, 2009

Question: My neurologist met an established patient at the hospital on Friday morning for evaluation of a headache and uncontrollable head-shaking. The doctor admitted the patient to observation at 8 a.m. and ordered lab tests and a CT scan. The shaking continued to get worse. My neurologist admitted the patient to the hospital as an inpatient at 1 p.m. for further diagnostic testing and treatment. His notes indicate a comprehensive history and exam, along with moderate medical decision making. Should I code this as an observation? Ohio Subscriber Answer: Do not use an observation code in this situation -- use an initial hospital care code. On the claim, report 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity ...) for the E/M with 784.0 (Headache) and 781.0 [...]
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