Initial Observation less than Detailed History

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

Moderators: NAMAS Moderator, Shannon DeConda

Post Reply
Posts: 9
Joined: Thu Mar 29, 2018 8:55 am

Tue Oct 23, 2018 1:41 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.

Posts: 9
Joined: Fri Oct 26, 2018 2:35 pm

Mon Nov 12, 2018 9:47 am

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
Posts: 11
Joined: Fri Apr 13, 2018 11:54 am

Wed Dec 05, 2018 5:25 pm

Working in a compliance department, we always give the direction of not billing at all. If the intent of the note does not reflect the CPT coded, we advise against billing another code. In your case, if the intent is Observation, but the notes does not support any of the observation codes, it shouldn't be billed at all. This would be a good way to get the provider the education he/she needs to bill.

By billing an establish outpatient CPT code, I could argue that you are committing Fraud by submitting a claim that you intentionally know to be false just to get paid. In essence, you are saying that the provider did XYZ, when he actually did ABC, knowing that ABC would not get paid.

i personally would not risk my organization for a few hundred dollars. This may never get caught, but you just never know. What if the patient gets a bill for an E/M code. He/she can easily open up a can of worms if he/she decides to go to the payer and ask why an E/M code was billed when he/she went in for Observation services. What are you going to say to them if that happens? The consultant said I could bill it this way because of the inpatient Q/A? Someone from AAPC/AHIMA board said I could bill it this way? I don't know? Without supporting documentations from government sources, you are fighting a losing battle and potentially open your organization up for an unexpected audit.

Just my 2 cents...
Corporate Compliance Analyst
Seattle Children's Hospital
Seattle, WA
Post Reply