Y92.230 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Short description: Patient room in hospital as place. The 2018/19 edition of ICD-10-CM Y92.230 became effective on October 1, 2018.
2018/19 ICD-10-CM Diagnosis Code Y92.230. Patient room in hospital as the place of occurrence of the external cause. Y92.230 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
NOTE: See the ICD-10-CM Official Guidelines for Coding and Reporting 2018, Section 1.b.10, Sequela (Late Effects), as well as the Code First notation for the subsection "Sequela of infectious and parasitic diseases (B90-B94)."
This is supported by Guideline IC.18.b, “Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis.” 25. How should we code neonates/newborns that test positive for COVID-19? (5/26/2020)
When a patient remains in observation beyond an initial date of service, separately report a discharge service on the day of discharge using 99217 Observation care discharge day management. CPT® clarifies that 99217 includes, “all services provided to a patient on discharge from ‘observation status’ if the discharge is on other than the initial date of ‘observation status.’”#N#Continuing with Example 2: If on day 2 Dr. Q deems the 68-year-old, insulin-dependent diabetic (admitted to observation status 10/12/16) ready for discharge, report 99220 for the first day and 99217 for discharge on day 2. If the patient remains in observation throughout day 2 and is released on day 3, however, report 99220 (day 1), 99225 (day 2), and 99217 (day 3 discharge).#N#No documentation of time is warranted for 99217; however, final exam, discussion of stay, and preparation of discharge record are required.
When coding observation services, there is a distinction between services lasting beyond 24 hours, and those lasting at least eight hours, but less than 24 hours.
When a patient is placed in observation status, know the documentation guidelines for time. Occasionally, a physician will need to observe a patient in the hospital for a time beyond that of a single-visit encounter. In these instances, instead of admitting the patient as inpatient status, the physician may admit the patient as observation status ...
If after day 3 the patient’s condition deteriorates and requires further monitoring, the physician could write orders admitting the patient to inpatient status. As stated above, when the patient is admitted as an inpatient, observation services are not reported for that day.
If the duration of observation care is less than eight hours on the same date of service, codes 99218-99220 are appropriate, but do not report the discharge (99217) separately.
If the patient’s condition warrants observation beyond 24 hours , the physician must provide adequate documentation (meeting the required two of the three key elements) to report a charge. The patient is considered “established” at this point.