ED Coding and Reimbursement Alert

Incorrect coding errors also plague these services.

It’s a common occurrence at your ED – the physician assigns the patient to observation status to keep an eye on his condition, and then discharges him the same day. You report 99234 and call it a day, right? Not so fast.

That’s the takeaway from a recent CMS report, which indicates that Comprehensive Error Rate Testing (CERT) reviewers looked at Medicare claims for 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 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity…).

The findings indicated that most improper payments for this code were due to insufficient documentation, indicating that something was missing from the records, while other issues were due to incorrect coding.

Background: When patients are under observation care for a period that spans between eight and 24 hours and are discharged on the same calendar date, you’ll pick a code from the 99234-99236 range, which includes the admission and discharge. In this situation, the documentation must meet the following three requirements, CMS says in its January 2019 Quarterly Compliance Newsletter:

• Documentation noting that the stay for observation care or inpatient hospital care involves a period between eight and 24 hours
• A notation that the billing physician was present and personally performed the services
• Documentation identifying that the order for observation services, progress notes, and discharge notes were written by the billing physician.

What the CERT Reviewers Discovered

Reviewers from CMS’ CERT team looked at claims for 99234 that were submitted to Part B MACs between April and June of 2017. They found that many records were missing documentation that would support 99234, and in most cases, the claims were missing one or more of the following:

• A valid physician’s order that includes all required elements.
• Documentation to support the services were provided or other documentation necessary t support the code reported.
• Hospital record.
• A properly authenticated record. If a signature is missing or illegible, a signature log is required.

Check this $135 mistake: Suppose the physician reports 99234. The CERT reviewer contacts the ED and asks for documentation of the observation visit. In response, the ED submits a discharge summary note for the date of service, as well as a history and physical note for the billed date of service, and a physician’s signature.

Although this sounds like sufficient documentation, the CERT reviewer marks it as having insufficient records, and the ED has to return the $135 payment.

Why? The documentation does not have a record of a physician order for observation services, which Medicare requires. This demonstrates that if even one aspect of the requirements cannot be located, the entire claim can be denied and the money repaid.

Some Improper Payments Were Due to Incorrect Coding

Not every error that the CERT reviewers found stemmed from missing documentation – some errors were due to incorrect coding.

Fore instance: The physician submits a claim for 99234 and the CERT reviewer requests documentation, which shows that the physician performed a comprehensive history and exam, along with moderate-complexity medical decision-making.

In this example, the reviewer found that the claim should have been coded as 99235 instead of 99234, and the ED is able to collect an additional $37, which is the difference between payment for 99234 and 99235.

Resource: To read the entire Medicare Quarterly Compliance Newsletter with the findings about observation care, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-MLN5862089.pdf.