ED Coding and Reimbursement Alert

When your ED physician performs observation services, the code choice will depend on the number of days (or hours) the patient remains in observation. And once you arrive at the proper code, you-ll have to make sure the supporting documentation is in order before sending the claim off.

You also need to make sure that the ED physician is actually providing the patient observation services before coding; often, what appears to be an observation is actually an ED E/M service.

Check out this primer on coding the different types of observation services.

For observation stays spanning more than one day, you will use 99218-99220 for the first day, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources LLC, in Deer Park, Ill.

The physician uses 99218-99220 for the patient's initial day of observation, "unless the patient is admitted to observation and subsequently discharged all on the same calendar day," she says.

These codes include all the E/M services the physician provides the patient that day (regardless of location). Therefore, you will not be able to separately report an ED E/M in most cases.

Warning: Gilhooly recommends coders look out for extended ED services that might appear to be observations but really aren-t. Attempting to categorize everyone who requires lengthy treatment in the ED as an observation patient is not good coding practice.

"By definition, someone is admitted to observation because you-re still trying to figure out whether they are sick enough to be admitted as an inpatient," Gilhooly says. Keep this in mind when deciding whether or not to report an observation code for your physician's service.

When the physician provides observation service to the patient over the course of more than one day, you should also report 99217 (Observation care discharge day management) to represent the service on the day of discharge, Gilhooly says.

Do not include 99217 on observations that last a single calendar day; the service must span at least two dates before 99217 is appropriate.

Example: A 48-year-old male with chronic obstructive pulmonary disease (COPD) presents to the ED with an acute exacerbation. Following the administration of nebulizer treatments and steroids, the patient is somewhat improved but not safe for discharge.

The ED physician writes an order to admit the patient to observation at 9 p.m. The patient receives several additional rounds of nebulizers along with repeat physician assessments overnight.

The next morning, the patient continues to stabilize, and a 6 a.m. blood gas shows significant patient improvement. The ED physician performs a final assessment at 7 a.m., which shows the patient is comfortable. The ED physician then writes a discharge order, along with a short summary of the patient's course of treatment.

For the initial date of service, 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) with ICD-9 code 491.21 (Obstructive chronic bronchitis; with [acute] exacerbation) appended to prove medical necessity. For the discharge date, report 99217 if the service is appropriately documented.

On your observation claims, Gilhooly recommends that you document the following:

- an admitting order

- date and time of admission

- any nursing or progress notes

- description of treatment physician provides during observation.

The other set of observation codes, 99234-99236, is for use when a patient is admitted and discharged within the same calendar day, says Tracey Koch, CCS-P, coding manager and technical research coordinator at Comprehensive Medical Management in Newport, Ky.

Example: A patient arrives at the ED at 2 a.m. Wednesday with syncope secondary to severe dehydration due to the stomach flu. By 8 p.m., the patient has responded positively to antinausea medicine and has stopped vomiting. She has received adequate IV fluids, and her blood work shows she's adequately hydrated.

A blood pressure check is stable, so the patient is sent home at 9:30 p.m. Encounter notes indicate a high-complexity observation service.

In this example, the patient's stay occurred on a single calendar day. So on the claim, you-d report 99236 (Observation or initial 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 comprehensive history; a comprehensive examination; and medical decision-making of high complexity) for the service.

Documentation alert: You should include the same type of documentation for these observation codes as you would for codes 99218-99220.

Also, be sure the record identifies "that the patient had been discharged on the same calendar day that she was admitted," Gilhooly says.

For Medicare and Medicaid payers (and other carriers that follow Medicare rules), the physician must provide at least eight hours of observation service before you can use 99234-99236, Koch says.

When coding single-day observation services of less than eight hours to Medicare/Medicaid, resort to codes 99218-99220.