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December 21, 2022

Dr. Smith admitted a patient to observation care services after seeing him in the emergency department with severe nausea, vomiting, and dizziness from dehydration.

The right CPT code for this scenario ?

Dr. Smith admitted a patient to observation care services after seeing him in the emergency department with severe nausea, vomiting, and dizziness from dehydration. The initial observation services documentation supported a comprehensive history, comprehensive exam, and moderate complexity medical decision-making. IVs were started, and the plan was to hydrate the patient and discharge him to home the next morning. The patient, however, had not improved enough the next day (day two) and was observed an additional 24 hours. The subsequent care documentation supported a problem-focused examination and low complexity medical decision-making. On day three, the physician’s documentation supported an observation care discharge service, and the patient was discharged home.

Reference

Herzing university discussion

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