Pt brought in for observation: Documentation must have a written order " pt placed on observation status" Initiation time must be documented and discharge time must be documented. A plan for observation and performance of periodic reassessments must be documented. A detailed or comprehensive history/ a detailed or comprehensive examination must be documented. A discharge summary must be documented. If you meet the documentation guiidelines you may use the observation codes 90218-99220 and subsequent (if pt stay more than a day) 99224-99226
If your record fall short of observation guidelines, then you MAYmeet the prolonged services , and again time must be documented and reassessment. In this case you would document the E/M done plus the additional time of reassessments. TIME must be documented ( total time spent with patient after the initial assessment, reassessing) and must document what was done.
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