Cracking the Code

Observation Service Code Observations

Observation care reporting can be a challenging area of medical coding. Patients are commonly ordered for observation services when they present to the emergency department and then require an extensive period of treatment/monitoring in order to determine their admission or discharge. Here are some helpful tips on how to successfully report observation service codes:

  1. Initial observation services are per calendar date, not per 24-hour period. Do not rely on length of stay in making determination of the correct CPT code.
  2. Confirm patient status. It is important to know whether the patient is in the hospital under “observation” status or “inpatient” status.
  3. The second day of observation begins at 12 A.M. even if the initial observation services were provided just an hour earlier. Second day of observation care should be reported with office or other outpatient visit codes 99211-99215.
  4. Physician documentation is key! Be sure that the provider’s documentation is concise and supports the observation service codes that are being reported.

 

Reference: References: https://www.cgsmedicare.com/partb/mr/pdf/observation_serv_factsheet.pdf CPT Assistant June 2011 pages 3-7: Observation care reporting
Scroll to Top
aquity awards and badges

We’ve won lots of awards. Find out why.

Send me info

Thanks for giving us your details. Our representative will contact you shortly.

Let's Talk

Thanks for giving us your details. Our representative will contact you shortly.

BOOK A DEMO

August 2022
Mon Tue Wed Thu Fri Sat Sun
1234567
891011121314
15161718192021
22232425262728
2930311234

Let's Talk

Thanks for giving us your details. Our representative will contact you shortly.

Call Now Button