Question Observation E&M stay 1 or 2 days?


Hinsdale, MA
Best answers
Please Help!
Patient came to ER after swallowing a fishbone.
Patient was triaged at 18.48 on Sept 10.
Our provider did OR procedure in the early hours of the morning on Sept 11. Patient was put in Observation.
Patient stayed overnight in observation, meaning in the early hours of Sept 11 after procedure.
Registration day and time is 04:24 on 9/11.
Patient was discharged on 9/11 at 13:38.
This isn't adding up to me since my provider said she saw patient in ED consult at 1:00 am and later did a scope/esophagoscopy in OR.
(how could the registration time be 4:24)?
I'm trying to determine if I need to code 1 CPT for OBSERVATION same day admit/discharge or 2 CPT codes for 2 day observation stay? plus surgery.


True Blue
Best answers
You can only bill one E/M code per date of service. Since the provider saw the patient in the ED, I would bill the consult, with modifier 25 or 57 since that's when the decision for the procedure was made. The observation E/M services in this situation are post-operative care on the same date and I would consider those incidental to the procedure.

The registration time sounds like the time that the patient was admitted to observation status, which is usually the time that the order was written.