ED Coding and Reimbursement Alert

Nail timing, proper notes for deserved reimbursement

Observation care can require a great deal of the emergency department physician's time - but reporting it shouldn't require a disproportionate amount of yours. Know your payer, when the care was rendered, and how much monitoring the doctor performed, and you'll have perfect claims in a snap.

Report Per Diem for Multiple-Day Care

Rule of thumb: When the physician performs multiple-day observation care, you should report services per day, regardless of payer.
 
If the observation time span straddles two dates in a row, report the initial observation code for the first calendar date (99218-99220) and then bill services on the date of discharge by reporting 99217 (Observation care discharge day management). Code 99217 should only accompany initial observation codes (99218-99220). You shouldn't include it with codes 99234-99236 (Observation or inpatient hospital care), because the relative value units (RVUs) allotted for these codes already include the costs related to discharge services, says James Blakeman, vice president of Emergency Groups' Office in Arcadia, Calif.
 
Example: The ED physician admitted a patient to observation status at 9 p.m. on one day, and discharged him early the next day at 6 a.m. For this patient, you'll report a code for the level of initial observation care (99218-99220) for the first calendar date, and the discharge code, 99217, for the second calendar date. Make sure the discharge note includes complete documentation, such as the following: "Full examination of the patient, discussion of hospital stay, instructions for continuing care, and preparation of discharge records," Blakeman says.

Count Hours for Same-Day Medicare Codes

In order to report same-day observation codes to Medicare, the ED physician must have observed the patient for a minimum of eight hours on the same calendar date, Blakeman says. If this is the case, you should report one of the following codes, depending on what the documentation supports:

99234 - 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 key components: a detailed or comprehensive history, a detailed or comprehensive examination, and medical decision-making that is straightforward or of low complexity

99235 - ... a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity

99236 - ... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity.

If the patient's visit is less than eight hours on the same date, you can only report the care with initial observation codes from the 99218-99220 series (Initial observation care):

  99218 - Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a detailed or comprehensive history, a detailed or comprehensive examination, and medical decision-making that is straightforward or of low complexity

  99219 - ... a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity

  99220 - ... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity.

Note: For Medicare patients receiving fewer than eight hours of observation care, most groups default to the ED evaluation and management codes (99281-99285).
 
Warning: Don't report 99234-99236 if the physician did not document periodic reassessments of the patient. Documentation with these codes is crucial, and the physician needs to have a record of progress notes describing the patient's condition during the stay in observation. The doctor should record the admission and the discharge under a separate heading. A separate sheet of paper is unnecessary.

Assume Lighter Load With Private Payers

Most private payers have more straightforward, less detail-driven policies for reporting same-day observation codes: The eight-hour minimum is not a threshold.
 
When you report same-day observation codes to a private carrier, you should use same-day admission and discharge codes 99234-99236, just as you would with Medicare, says Dee Mandley, RHIT, CCS, CCS-P, director of HIS and education services for CURES, a coding and compliance company in Twinsburg, Ohio. With most of these payers, you can report same-day observation codes regardless of the length of stay, as long as documentation shows that the physician performed both an admission and a discharge.