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Last Modified: 3/15/2018 Location: FL, PR, USVI Business: Part A, Part B

At what time and date does observation care begin?

Q. Does the documentation of the time and date that a patient is in observation care pertain to the time during which the patient was admitted to observation care, or does it start at the time that the physician provides services (i.e., completes a history and physical)?
A. Per the Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM):
Observation time begins at the clock time documented in the patient’s medical record, which coincides with the time that observation care is initiated in accordance with a physician’s order.
Observation time ends when all medically necessary services related to observation care are completed.
Specific coding guidelines are given in the IOM, based on the total time during which the patient is admitted for observation care, without regard to when specific services are provided.
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