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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
    Default
    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
    Location
    Columbia, MO
    Posts
    12,531
    Default
    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
    Default
    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
    Location
    Columbia, MO
    Posts
    12,531
    Default
    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
    Location
    Greenville, SC
    Posts
    51
    Default
    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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