Neurology & Pain Management Coding Alert

You Be the Coder ~ Coding Observation in Non-Observation Unit

Question: Our physician performed an observation service on a patient who was not in the hospital's observation area. Can we still report an observation code for the visit?

Texas Subscriber

Answer: Location is not the most important factor when deciding whether to use an observation E/M code. The patient does not have to be in a designated observation unit for you to use the codes.

When you code observation services, select from 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient -) for new or established patients.

Remember it this way: Observation is a status, not a location where the service occurs.
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