Our physician admitted an established patient directly from our office late Monday night after performing an evaluation and management (E/M) service. The physician was worried about dehydration and high fever. He called over orders to the hospital but did not see the patient in the observation unit until Tuesday. The patient was improving, but the fever was still not under control. He decided to keep the patient in the unit. On Wednesday, our physician evaluated the patient and determined the patient could be released. What codes do I report for all three days?

Since your physician had a face-to-face encounter in the office on Monday but never saw the patient in the observation setting that day, report an appropriate code from the office/other outpatient E/M services (99212-99215).

On Tuesday, since a face-to-face encounter occurred in the observation unit and the patient was not discharged, report the appropriate initial observation care...

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