There currently is no CMS directive regarding Observation level of billing. Please review the information below on reporting Initial Observation Care Services:
When documentation does not meet the required E/M elements for the lowest level of Initial Observation Care service (Detailed History, Detailed Exam, Straight Forward/Low Medical Decision Making):
- Report the lowest level initial Observation Care E/M code
- Educate provider on missing E/M elements
This is CU Medicine's current guideline.