Same Day Admit/Discharge Observation Care

ndrummond

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Can anyone help me with how to code for observation care when the patient was admitted to the ER at 8:30 pm, then the admission status was changed to Observation at 2:15 am the next calendar day and the patient was discharged at 10:30 pm on the same day that the patient was admitted to Observation care. My provider is billing for same day admit/discharge. I'm not sure if this should be initial observation care or same day admit/discharge observation care. Does the same day admit/discharge time start when the patient is admitted to the E/R or when their admitted to observation care?
 

cgaston

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Waiting in the ER does not constitute an admission to the hospital.

It is my understanding that admission occurs when the Physician documents it in the record. In your case, the patient was admitted to observation and discharged on the same day so the 99234-99236 codes are appropriate.


When my General Surgeons note admission during an evaluation done on day 1 but the hospital doesn't get it in the system until day 2 I still use day 1 as the admission date. I have the documentation which is the most important part of coding, right??!?! :)
 
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