Ob-Gyn Coding Alert

Question: Who determines observation status, and how should I code for additional hospital days once the patient is admitted? A patient was in for over a week with premature ruptured membranes at 27 weeks of pregnancy. The physicians monitor her every day.

North Carolina Subscriber

 
Answer: Observation status lasts for 48 hours at most. With observation status, the physician essentially doesn't know whether to admit the patient or send her home, but feels the condition is serious enough to warrant observation. A patient is generally admitted under observation on one day (99218-99220) and on the second day is either sent home (99217) or discharged from observation and admitted to the hospital (you will be billing only for the hospital admission, in this case, 99221-99223).
 
Or, you may admit the patient under observation and discharge her the same day, either to home (99234-99236) or to the hospital. Again, if she is admitted to the hospital directly from observation care on the same service day, only a hospital admission is billed, but all services provided to the patient that day are counted toward the level of E/M service. If the observation is only for a few hours and the patient's condition is not particularly serious, use the outpatient-service codes, 99201-99215. Remember that the physician must have seen the patient in order to bill for observation care and that these codes do not have a time component, so all three of the key elements of history, exam and medical decision-making must be documented in the record before you can bill.
 
Because the patient you mention has been admitted to the hospital, each hospital day can be billed by the attending physician because they would be outside the global package. You would bill the hospital-admission code (99221-99223) and then for each subsequent hospital visit using 99231-99233. Remember that the care that occurs 24 hours prior to delivery is included in the global ob package.