tci ED Coding & Reimbursement Alert - 2000 Issue 5

Documentation Is Key to Getting Paid for Observation

When a patient presents to the emergency department (ED) with chest pain, the pain could be a cardiac problem or just indigestion. The physician needs to order specific diagnostic tests, interpret the results and observe the patients condition over time to make the proper diagnosis. Comprehensive documentation will avoid denials of reimbursement for such observation care.Most EDs hold patients in observation from time to time, and some departments even have specialized units dedicated to observation services (observation units, chest pain centers, critical decision units, etc.).Because treating a patient in observation involves more physician work and time...

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