Wiki Question on Observation codes and correct POS

[mchaidez]

Hello,

I always have trouble identifying the POS when I code Observation codes.
Sample: Patient presents to ED department and There is a Emergency Department H and P - Per ED physician note- Call placed to on call hospitalist Dr. X who will admit to tele.

I will be billing for Dr. X (Only included the key terms)
Dr. X :
History and Physical
Chief Complaint: Trauma to the head
HPI:
this is a 72 years old female with history of hypertension, diabetes type 2, hyperlipidemia , reports that the patient
was robbed earlier this morning, patient reports falling to the ground hitting her head, denies loss of consciousness,
aware of her surrounding immediately after the fall. Denies nausea, vomiting, diplopia, trouble with vision.
At this time patient complained mild headache posterior to the head, able to move all extremities without any
weakness
Assessment/Plan:
# 2 mm acute parafalcine subdural hematoma.
# Posterior parietal scalp hematoma
# HTN
# HLD
# DM2 on Metformin
- admit to obs
- PT/OT
- keep SBP < 140, start on Labetalol PRN and Losartan
- neurocheck q2h
- telemetry
#DIET cardiac diabetic diet
#DVT PPx SCD
Disposition: admit to obs, plan for dc home in AM

***and patient was discharged next day.
So, in this case I coded:
99218
99217 with POS (23)
or should I use (22)?

Please advise.

Thanks,
M

 

[AmandaBriggs]

I recommend that you read the sections in CPT prefacing the observation (especially the section "Initial Observation Care") and emergency E/M codes as this should give you a clue as to the correct POS.