# Observation Care - If a patient seen in the ED is placed



## thack97 (Apr 10, 2014)

If a patient seen in the ED is placed in a "observation status" (same TID as ED) and later discharged, can 99217 be submitted along with the ED code?  Basically, must 99218-99220 be billed/submitted to bill the discharge 99217?


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## jimbo1231 (Apr 10, 2014)

*ED Vist bundled in*

In that scenario, the ED visit is bundled into the 99218-220. and if the patient is discharged the following day, 99217 is coded. Of course the documentation must support the Observation Services coded. If the patient is discharged on the same day, and there are 8 hours of Observation, 99234-6 would be coded.

Jim


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## thack97 (Apr 10, 2014)

My physician doesn't want to complete a separate H&P from the ED visit.  So our plan is to bill the ED visit, place the patient in the "observation status" and at time of discharge, submit 99217.  I haven't found anything stating you MUST bill 99218-99220 to bill 99217.


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## OCD_coder (Apr 10, 2014)

*You would not perform a separate H&P for the OBS*, but the patient status has changed from ER to OBS and you should be selecting the appropriate code based on the service provided (MCR rule see below source sited), you would use only one note and one E&M for a single DOS.  The provider should document the time the patient was placed in OBS within his note or in the physician orders.  You cannot bill a 99217 and an ED 9928X on the same DOS and the same POS.  You could only bill a 99217 if it occurs on the 2nd calendar day, period. 

What jimbo is stating is that if the patient meets the MCR required time threshold of a minimum of 8 hours of time on a single calendar date then they would need to select a 9923X Obs Same day admit/discharge code family.  *If the patient was in OBS for less than 8 hrs and/or time was not documented then the appropriate code would be in the code family 99220-99218 Initial OBS admit.*  The ER codes are no longer applicable once the patient is placed in Observation.

Medical Claims Processing Manual (IOM) 100-4, 12, 30.6.8 Payment for Hospital Observation Services.


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## thack97 (Apr 10, 2014)

Thank you for all the feeback.  So when pt is seen in the ED, code CPT 99281-99285 is submitted.  Pt is placed in observation status while remaining in the ED.  Rather than submitting Initial observation code 99218-99220, we will submit the ED code.  When discharging the patient from Observation(separate day from ED visit), we would submit 99217.  Is this scenario acceptable?  Or MUST you bill 99218-99220 to bill 99217?  I'm not locating anything that states you MUST bill the initial obs codes.  The documentation will reflect the medically necessity to be placed in an observation status along with appropriate documentation while in the obs status.


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## jimbo1231 (Apr 10, 2014)

*Don't think so*

So you are proposing say a 99284 for Day 1 and a 99217 for Day 2? I think you have a couple of issues there. I think you will be dealing with a lot of payor denials when you combine an ED visit with an Observation Day discharge. And you are right, the CPT doesn't say that an Observation Service is required to bill for an Observation discharge. But it is implicit if you are using a discharge code there would have been an admission, and your physician should document an admission to Observation for the medical record to be accurate. And as OCD stated, the documentation for Observation isn't that demanding and the codes pay better. Also if you look at 99238 it doesn't expicitly state the patient had to be in the hospital to code for a discharge. But that doesn't mean you can code an outpatient visit followed by a hospital discharge code.


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