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  1. Default Observation
    Medical Coding Books
    Must a document state that a patient is being "admitted" to observation, in order to bill 99218-99220. If the report is titled "observation or outpatient note", does that suffice?

  2. #2
    A patient is in observation when a physician documents an order in the hospital chart admitting the patient to that status. It shouldn't matter what is stated in the E&M note itself as the status will be determined by that order and the code choice for observation would be dependent on that.
    Thomas Field, CPC, CEMC

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