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2 hr observation

  1. #1
    Default 2 hr observation
    Medical Coding Books
    I was asked about a case where a patient was not seen in the past 5 yrs and came to the office for high B/P. He was given clonidine (pill form) and observed for 2 hrs. The patient was a self pay and the doctor wished to use a code for an established patient so he wouldn't be charged as much.

    This is just a scenario I was asked about. What in the world would you code for that?
    Alicia Scott, CPC, CPC-I, CRC
    Educational Director, CCO.us,
    Have a Passion for Coding

  2. Default
    Quote Originally Posted by Alicia Scott View Post
    I was asked about a case where a patient was not seen in the past 5 yrs and came to the office for high B/P. He was given clonidine (pill form) and observed for 2 hrs. The patient was a self pay and the doctor wished to use a code for an established patient so he wouldn't be charged as much.

    This is just a scenario I was asked about. What in the world would you code for that?
    A new patient code 99201-99205 based on documentation. I would not code established for reimbursement or any other reason if it clearly should be coded as a new patient. PERIOD. A provider has control over how much information is documented in the note. However, if they document a note with minimum information so a low e/m is billed and the patient gets sicker (high B/P leads to heart attack or stroke) they open themselves up for malpractice type issues.
    Dee
    CPC, CPCO, CPMA, CPCD

  3. #3
    Red face Thank you
    I have talked to the nurses and think that I explained it enough. I appreciate your comments. Many small offices I think feel they are not going to be audited because they are small but that is not true.
    Alicia Scott, CPC, CPC-I, CRC
    Educational Director, CCO.us,
    Have a Passion for Coding

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