Wiki Observation Admit - CPT 99218-99220

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maryv22

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Good morning,

If there is not enough documentation to support an initial observation admit (99218-99220), would you change this to a subsequent visit (99224-99226) or consult visit (99241-99245)?

Thanks,
Mary
 
danskangel313 said:
Can you provide specifics and more information?
Click to expand...

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?
 
The coding on this all basically depends on the exact directions documented by Ortho. The documentation from Ortho has to have an order indicating an admit. Normally a patient is placed in observation status while the provider determines whether to admit or not. I can't see an admit to observation status being done if a decision for surgery had been made, so I'd assume they are admitting to inpatient.

You will need to review the documentation and find the admit order as it will indicate observation or inpatient. You will also need to find out if the Ortho provider's evaluation meets the criteria to qualify as a consult. In addition, does the documentation state when the surgery will take place? That could add in the possible need for modifiers and so forth. I can't really give you an answer one way or another without that information.

Also, is this a Medicare patient?
 
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