Initial Observation less than Detailed History

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Initial Observation less than Detailed History

Postby Gibbons86 » Tue Oct 23, 2018 5:41 pm

The Physician ordered the patient to be in Observation status and the stay was longer than 24 hours in Observation, meeting 99218-99220. However the initial visits History is only Expanded due to missing PFSH and HPI components. Since we do not meet all 3 components for the lowest code 99218, do we default to NP Outpatient code 99202 for that initial Observation visit? I see where CMS allows a subsequent visit code for Initial Inpatient visits when all 3 components are not met, but I do not see where this is also allowed for Observation codes.

Thanks!!
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Re: Initial Observation less than Detailed History

Postby shutchins » Mon Nov 12, 2018 2:47 pm

Since it seems you are an internal coder/auditor- I would actually recommend first you query the provider and ask him to review the documentation to see if all work that was performed has been documented. Keep in mind that providers are human too and mistakes happen.

If the provider indicates that the documentation is correct in it’s current format than you code the appropriate outpatient LOS based on the documentation you do have.


Your Question was answered by Shannon O. DeConda, CPC, CEMC, CEMA, CPMA, CRTT
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