CPT Code 99218 Initial observation care, per day, for the evaluation and management
of a patient which requires these 3 key components: A detailed or comprehensive
history; A detailed or comprehensive examination; and Medical decision making that
is straightforward or of low complexity. Counseling and/or coordination of care
with other providers or agencies are provided consistent with the nature of the
problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring
admission to “observation status” are of low severity.
Rationale Hospital observation service codes are used to report services provided
to patients designated as under observation status in a hospital. Observation services
may be provided in an observation unit or some other hospital unit. These codes
include the initiation of the observation status, supervision of patient care including
writing orders, and the performance of periodic reassessments. These codes are used
only by the physician “admitting” the patient for observation. These codes are not
determined by whether the patient is new or established. These codes are selected
based upon the three key elements of history, exam, and medical decision making.
The history elements: Chief complaint present, HPI was extended (4 or more elements),
ROS was complete (10 or more systems), and PFSH was complete (3 of 3 elements) for
a detailed level of history. The exam under the 1995 guidelines met the requirements
for a detailed exam (2-7 organ systems with at least one more detail). The exam
under the 1997 guidelines does not meet the requirements for a detailed exam (12
elements identified by a bullet in two or more areas/systems of the general multi-system
exam or 2 elements from at least 6 systems). The medical decision making elements
documented included: Number of diagnoses or management options was multiple with
a new problem. Amount or complexity of data was low (ordering of radiology testing
and lab testing). Table of risk was moderate (acute illness with systemic symptoms).
The final level of decision making is moderate. The history level was detailed,
exam level was detailed, and medical decision making was moderate. All three key
component levels must be met or exceeded for an observation encounter. The levels
of key elements meet those required for code 99218.
ICD-9-CM Codes 276.51 Dehydration 558.9 Other and unspecified noninfectious gastroenteritis
and colitis 780.60 Fever, unspecified
Rationale Dehydration is characterized by excessive free water loss and plasma volume
contraction disproportionate to the loss of sodium. Solutes become imbalanced resulting
in hypernatremia (increased concentration of serum sodium) as an indicator for true
dehydration. Blood volume can be replaced, but the plasma solutes must be correctly
balanced as well. Gradual volume restoration is imperative to restore optimal fluid
balance slowly.
Dehydration may follow bouts of diarrhea, vomiting, or profuse sweating. It is often
a manifestation of the patient’s illness (e.g., gastroenteritis), and in such cases,
the code for dehydration would not be sequenced first. However, if the patient’s
dehydration becomes significant enough to warrant separate treatment for rehydration,
the dehydration code would be sequenced first.
In addition, code 780.60 is assigned because the documentation clearly states that
the patient presented with fever.
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