Observation Coding

If a patient presents for Initial Observation care (99218 – 99220) but the documentation does not support the minimum requirements for the three key components do we assume to follow the same as the IP scenarios where we then use subsequent Observation Care codes (99224-99226) instead or would we revert to Outpatient service codes (9920x – 9921x)?

re: Observation Coding

This isn't described in the Medicare manual, about what to do in this situation.

It might be worth a call to your payer to see which they prefer. I would suggest (unfortunately) either the unlisted code 99499 or an outpatient visit code 99201--99215. I think that the outpatient code correctly describes the service performed, but I can't point to anything in the manuals to support my opinion.

And of course, the right place of service.