Q My patient who was 7 months pregnant presented to the ER with abdominal pain. She was sent to labor and delivery, where I treated and discharged her. Should I use the observation codes for this or just an outpatient visit code?
A You need to determine whether you admitted the patient to observation status (which is not the same thing as admission to the hospital) or saw the patient, treated her, and then sent her home.
Timing is everything. Although the codes for observation care do not stipulate a time period, the record must clearly show that she was observed before a determination could be made to send her home or admit her to the hospital. This would include being seen first by you and then having nursing staff observe for problems prior to your deciding to send her home.
The observation codes require, at a minimum, documentation of a detailed history and exam (with any level of medical decision making). If your patient was admitted and discharged on the same service date, the codes you would select from are 99234-99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date).
If, on the other hand, you saw the patient, treated her, and then immediately released her to go home or you left orders to send her home after a test had been performed such as a nonstress test, you should consider this to be an outpatient service and you would report one of the established patient problem codes (99212-99215).
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.