ED Coding and Reimbursement Alert

Careful: New 'middle day' codes could complicate your claims.

There's something old and something new in multiple-day observation reporting this year, as CPT added a new code set to represent observation coding scenarios that last more than two calendar dates.

Take a peek at this primer to make sure you're coding your multiple-day ED observation encounters correctly in 2011.

Code 2-Day Stays the Same

If the patient is in observation for multiple days, you'll still choose a code from 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: ... ) to represent the first day of observation, confirms Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

"Per CPT, 99218 to 99220 apply to all evaluation and management services that are provided on the same date of initiating observation status," Pohlig explains. These codes "should not be used for post-operative recovery if the procedure is considered part of the surgical "package."

Report 99217 (Observation care discharge day management ...) for the discharge service when an observation service spans more than one calendar date.

Consider this detailed clinical scenario from Jill M. Young, CPC, CEDC, CIMC, founder of Young Medical Consulting, LLC in East Lansing, Mich.:

At 9 a.m. Thursday, March 17, a patient sees her personal care physician (PCP) after an asthma attack. The PCP gives the patient a nebulizer treatment, and the patient feels better. Later that morning the patient calls the PCP saying that the she is again experiencing wheezing and shortness of breath.

The PCP directs the patient to the ED, where the ED physician documents a detailed history and physical exam, and recommends she be admitted to observation status for her acute asthma attack. Time of admittance is 11:39 a.m. Thursday. The physician orders an IV for the patient, who is given medications to treat her presenting symptoms. The physician also orders nebulizer treatments at frequent intervals.

At 6 a.m. Friday, March 18, the patient's wheezing is gone and she indicates her shortness of breath is greatly improved. She is discharged from observation care at 7 a.m. with instructions to return to the ED if the wheezing returns and she cannot control it with her rescue inaler.

For this encounter, you should report the following:

99218 (... a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity ...) for the first day of observation care

99217 for the discharge from observation

493.92 (Asthma; asthma, unspecified; with [acute] exacerbation) appended to

99218 and 99217 to represent the patient's asthma.

Remember Documentation on Multi-Day Stays

When reporting multiple-day observation stays, be sure to include this documentation, says Joan Gilhooly, PCS, CPC, CHCC, vice president, AuditServices and Compliance for Health Management Resources in Salisbury, N.C.:

• Date and time of admittance
• Nursing notes
• Progress notes
• Description of the treatment the physician provides during observation.

Sample notes: Consider the above example, in which the asthma patient stays in observation for two days. For this claim, the proper documentation would have to include, at a minimum:

3-Day Stay Calls for New CPT Codes

In the rare event that a patient's observation stay spans three calendar days, you would report the middle day with a code from the 99224-99226 (Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: ... ) set as of Jan. 1, 2011.

Consider this example from Young:

A type II diabetic patient on vacation presents to the ED with a history of prolonged vomiting and concern about maintaining her sugar levels. After examination, the ED physician recommends admission to observation status for gastroenteritis. An IV is started on the patient, who is given fluids and other medications as treatment for the presenting symptoms. Notes indicate the physician provided moderate-complexity observation service.

Although the patient initially improves, she starts to have minor changes to her blood sugars early Tuesday,and the vomiting returns. The physician makes changes to her insulin dosage, and increases her IV fluids and antiemetics. The physician decides to keep the patient in observation Tuesday night just to be sure there is not another exacerbation. Notes indicate a moderatecomplexity observation service occurred Tuesday.

On Wednesday morning, the patient's sugars are stable and the vomiting has abated. The physician discharges the patient from the observation unit Wednesday morning. For this encounter, you would report the following:

• 99219 (... a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity ...) for the first day of observation care (Monday)
• 99225 (...an expanded problem focused interval history; an expanded problem focused examination; Medical decision making of moderate complexity ...) for the second day of observation care (Tuesday)
• 99217 for the discharge service (Wednesday).

Caveat: Though CPT instructs coders to use 99224-99226, some carriers might still ask for 99499 (Unlisted evaluation and management service) to represent the middle day, Young warns. If you are at all unsure about the insurers' 99224-99226 policy, clear things up with a call before filing your next three-day observation service.