documentation

what documentation EXACTLY do I need to submit for code 99226 with modifer 25. what specifically do I get from the hospital records. I am new so basic terms please.

re: documentation

So, you are saying the physician had a subsequent day encounter in Observation by the admitting doctor. And, on this day a minor procedure was performed. Code 99226 should document that the patient is still not stable or has a significant complication or new problem. You need a detailed history and/or physical documented and the medical decision making must be of high complexity! There must also be documentation of the minor procedure performed.