tci ED Coding & Reimbursement Alert - 2019 Issue 3

Observation Care: CMS Finds Observation Care Claims Often Lack Appropriate Documentation

Incorrect coding errors also plague these services. It’s a common occurrence at your ED – the physician assigns the patient to observation status to keep an eye on his condition, and then discharges him the same day. You report 99234 and call it a day, right? Not so fast. That’s the takeaway from a recent CMS report, which indicates that Comprehensive Error Rate Testing (CERT) reviewers looked at Medicare claims for 99234 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3...

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