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observations vs. admission

  1. #1
    Question observations vs. admission
    Medical Coding Books
    If a patient was in the hospital for observation and was admitted would you charge an initial observation e/m (ex: 99218) or an initial hospital admit (ex: 99222)? It looks like the patient was in observation and admitted on the same date.

  2. #2
    Greeley, Colorado
    I would say code the inpatient admission. You can use both the documentation for the obs admit and the documentation for the inpatient admit for your level of service. You won't be able to code both.
    Lisa Bledsoe, CPC, CPMA

  3. #3
    I totally agree with Lisa.
    For more info you can check the CPT 2009 book, page 13:
    "When a patient is admitted to the hospital from observation status on the same date, the physician should report only the initial hospital care code. The initial hospital care code reported by the admitting physician shoud include the services related to the observation status services he/she provided on the same date of inpatient admission."

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