Health Information Management

Tip: Know when to bill post-operative observation separately

APCs Insider, December 14, 2012

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

Coding for observation services can be confusing and complicated. The following case study explains when to report observation for a post-operative patient.

A patient underwent a left ­inguinal ­hernia repair Tuesday morning. The physician writes an order to place the patient in observation ­following surgery for postop pain control. The nurse documents the patient arrived in recovery at 11 a.m., had no complications, and received no non-routine post-op ­services. The physician discharged the patient at 11 p.m.
 
Even though the patient was being observed for 12 hours, the facility cannot bill for observation services. The observation was part of the regular postoperative treatment and should be billed as recovery room services.
 
What if the physician documented a postoperative complication that requires observation? That changes the ­situation. Since the patient is placed in observation because of a complication, the facility can bill for observation as long as the physician writes an order and the nurse ­documents the start and stop time for the observation.
 
The tip is adapted from “Walk through observation case studies” in the December Briefings on APCs.



Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

Most Popular