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Admit or Observation

  1. #1
    Default Admit or Observation
    Medical Coding Books
    What are the guidelines on documentation between the two ??

  2. #2
    The requirements as far as History, Exam, and MDM are actually the same for both.

    What guidelines are you referring to?

    Laura, CPC, CEMC

  3. #3
    Columbia, MO
    I am with Laura, other than what she has stated you must have a physicians order, you cannot bill observation if the order states admit and vice versa

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    I understand the coding part is the same for all e/m's but i'm reffering to the documentation. My physician will do a H&P and put admit to observation then follow the patient on the floor. I do the billing for surgery doctor's so most of the time the patient requires surgery within the next few days.

  5. #5
    Columbia, MO
    He says obsevation so that is what it is, if the stay is over 23 hours then he needs to be prompted for a new order to convert to inpatient.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Greenville, SC
    Actually, doesn't CPT guidelines state that there is no specific time guideline for observation, just that anything past the first date would be reported with the regular outpatinet codes 99212-99215? Claim may be denied for medical necessity after 48 hours, but....

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