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Coding Initial observation care
Posted By Mary Peabody on 05-05-2020, 16:08:57 in Ob-Gyn
Hello Melanie,

CPT 99218-99220
Documentation requirement for initial observation care is at list a detailed or comprehensive history and detailed comprehensive examination for CTP 99218, is documentation does not support a detail history or PE, do you report the subsequent observation code codes

Also for CPT 99234, if the documentation does not support detailed history and examination, how would you report the observation?
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Posted By Melanie Witt on 05-06-2020, 15:47:44
The rules are concrete. You only have 2 choices if the documentation requirements are not met: code is as an outpatient service that qualifies or code is as an unlisted E/M service. But BE SURE to do provider education so this does not happen again.
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