Health Information Management

Tip: Know when to code for post-operative observation

APCs Insider, December 28, 2012

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A patient underwent a left ­inguinal ­hernia repair Tuesday morning. The physician writes an order to place the patient in observation ­following surgery for post-operative pain control. The nurse documents the patient arrived in recovery at 11 a.m., experienced no complications, and received no non-routine post-op ­services. The physician discharged the patient at 11 p.m.

Facilities cannot bill for the 12 hours the patient spent in observation because the observation is a routine part of post-operative care.
 
However, if the physician ordered observation because the patient suffered a complication, the facility could bill for that observation. In this case the observation was not a routine part of the post-operative care.
 
The tip is adapted from “Walk through observation case studies” in the December Briefings on APCs.



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