ED Coding and Reimbursement Alert

Learn to ID observations, which pay about  60 percent more than E/Ms

When your ED physician performs observation services, you must be ready to differentiate between the two types of observation codes. For the most spot-on claims, coders also need stellar documentation from encounter forms so they can choose the proper procedure and diagnosis codes.

Further, failure to differentiate observation services from standard evaluation and management services will hurt your practice's bottom line. For level-two observation code 99219, Medicare pays about $99.67, says Caral Edelberg CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth, Jacksonville, Fla. For level-two ED E/M code 99282, Medicare pays about $37.14, Edelberg says.

Code First Day of Stay With 99218-99220

The first of the two observation code sets you-ll use is the 99218-99220 family: Report these codes for the first day of observations that span more than one calendar date, Edelberg says.

-These observation admission codes are reported only by the supervising or attending physician when the patient is admitted to observation. These codes include initiation of observation status, supervision of the care plan for observation, and performance of periodic reassessments,- she says.

Example: A male patient presents to the ED at 6 p.m. with a moderate asthma exacerbation. After two hours of nebulizer treatments, the patient has mildly improved but is not safe for discharge. The ED physician admits the patient to observation status at 8 p.m., hoping to forego the need for inpatient admission with additional nebulizer treatments. The patient receives additional nebulizer treatment overnight.

In the morning, the respiratory rate is noted to be normal, and the patient's wheezing has subsided. The ED physician writes a discharge order at 7 a.m.

On the claim, you would:

- report 99220 (Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) for the observation.

- link 493.92 (Asthma, unspecified; with [acute] exacerbation) to 99220 to represent the patient's asthma.

Remember to Note Physician Involvement in Your Observation Documentation

On your 99218-99220 claims, include proof that the patient was in the care of the ED physician during the observation period. You can prove this with notes in the medical record -for admission, discharge, and other appropriate progress notes that are timed, written, and signed by the physician,- says Marianne Wink-Sturgeon, RHIT, CPC, ACS-EM, at New York's University of Rochester Medical Center.

The medical record must include documentation showing that the physician explicitly assessed patient risk to determine that the beneficiary would benefit from observation care.
 
-Also, documentation must support the level of service charged,- Edelberg adds. For example, if the physician reports 99220, your documentation must support a medically necessary comprehensive history, comprehensive examination and medical decision-making of high complexity. Further, all three key components (history, exam, medical decision-making) must meet or exceed the level of service selected. Observation codes are not billed based on time, she says.

You should note that for observation services, a comprehensive history requires three of three areas of PFSH, unlike an ED E/M, which only requires two of these three history components at the comprehensive history level.

In the above example, the patient was in observation for more than one day, so you should code the discharge service as well. Report discharge services with 99217 (Observation care discharge day management).

Use These Codes for Longer 1-Day Observations

If a patient is in observation for more than eight hours but is still discharged on the same day, you should choose the appropriate code from the 99234-99236 set.

-These codes are used when the patient is in and out within a 24-hour period on the same date; the observation time cannot span two dates,- Wink-Sturgeon says. These codes represent admission, observation and discharge services, so don't report 99217 with the  99234-99236 codes.

Example: A 46-year-old male presents with generalized chest pain at 10 a.m. There is no radiation of the pain and it is not exertional. After performing an initial evaluation and an electrocardiogram, the ED physician admits the patient to observation status. The physician performs two sets of cardiac enzymes, and then a stress test (results negative). The patient's pain resolves, and at 9 p.m. the physician discharges the patient.

In this instance, the patient spent a total of 11 hours in observation on the same calendar date. On the claim:

- report 99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) for the observation.

- link 786.50 (Chest pain, unspecified) to 99236 to prove medical necessity for the observation.

Documentation: On your 99234-99236 claims, Wink-Sturgeon recommends that you include notes:

- explaining the admission and discharge of the patient
- outlining each time the physician checks the patient (and the physician's actions during those checks)
- clarifying the length of the observation status.

Also remember to include timed physician/nursing notes for the encounter, -and a discharge note including follow-up care advice,- Wink-Sturgeon says.

Edelberg says your discharge note should include:

- a description of the final examination of the patient
- a discussion of the hospital stay
- instructions for continuing care to all relevant caregivers
- preparation of discharge records, prescriptions and referral forms.

-I always advise folks to look at their local carrier policies for additional guidance [on observation documentation],- Wink-Sturgeon says.