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Observation Documentation

Tierni Posted Wed 23rd of September, 2015 14:57:07 PM

We have an Interventional Cardiologist who often sees patients at the hospital in an Observational setting; which we then bill accordingly. However, his notes "never" state anything related to the patient being in an Observation status.

Should his progress notes state somewhere the patient is in observation, or being discharged from observation (if in fact that was what was going on)? Or is it not important to reference the patient is in an observational status in order to use observation cpt's for billing purposes?

SuperCoder Answered Thu 24th of September, 2015 04:57:37 AM

Thanks for your question.

Interventional cardiologist should mention in his progress note that the patient is in "observation status or discharge from observation."

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