Can you provide specifics and more information?
The components to support the lowest level of an Observation Admit is the following:
History – Detailed or Comprehensive
Exam – Detailed or Comprehensive
MDM – Straight forward or Low Complexity
Scenario:
The patient came through the ED due to a fracture. Ortho saw the patient in the ED and decided that they would admit patient for surgery.
The history is Expanded Problem Focused. Since it is an EPF history, this would not support an Observation Admit since you need at least a Detailed history.
So, do the same rules apply to Observation as it would Inpatient where you would only bill for a subsequent visit, CPT 99225?