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Surgery then stayed overnight. Which e/m??

  1. Default Surgery then stayed overnight. Which e/m??
    Medical Coding Books
    I have two patients that came in for outpatient surgery and ended up staying overnight. My provider wants to bill the hospital subsequent codes? Is this correct? Or should I be billing an initial observation code? Not even sure if I am in the right forum. But if anyone is able to help that would be great!


  2. Default Documentation/Place of Service

    Youstated the patients had outpatient surgery. Where did the patients stay overnight? Were they admitted to the hospital? If they didn't stay in a hospital you can't use hospital subsequent codes. For observation there would have to be separate documentation for admit to observation, plan of care as well as the physician documentation. Also you are probably dealing with the surgical package that goes with the procedures. So we need some more info.


  3. Default Little Coder
    Hi, Jim

    What if the patient has a minor procedure, let's say that the global is 0 day, and the patient stays as outpatient overnight, can the subsequent day be billed as an established outpatient visit since it is already out of the global? can you please provide some reference resource eg...CMS? thank you.

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