ED Coding and Reimbursement Alert

Tackle these troublesome infusion and diagnosis questions.

Coding for the observation care setting presents several potential issues — the biggest of which involves being in the hospital but still being considered an outpatient. Plus, insurers have strict requirements about what counts as a “day” in observation, and often, the ED staff is left figuring out the answers to the confusing issues.

Three coders from Connecticut’s Hartford HealthCare have submitted their most pressing questions to ED Coding Alert, and we’re breaking down the answers with expert advice and tips from insurers. Read on to get the answers to these commonly asked questions.

FAQ 1: Which is the Principal Dx?

Question: Susan Kelly, CPC, is seeking guidance on how to report the diagnosis codes on an observation claim: The outpatient coding guidelines refer to the first-listed diagnosis to be used in lieu of the principal diagnosis. Often, the first listed diagnosis on the discharge summary is not the reason for the admission to observation. Should the reason for admission always be the first listed? If a patient is admitted for syncope, and the provider documents that the patient is dehydrated and is now in acute kidney failure and all the treatment was for the acute kidney failure/dehydration, should syncope still be the first listed diagnosis?

Answer: You should report the diagnosis that’s chiefly responsible for the visit rather than the diagnosis listed first on the discharge summary. Because observation care is considered an outpatient service, you’ll follow the outpatient coding rules, which dictate that, in your example, you’d report the diagnoses for acute kidney failure first, followed by dehydration. You may also report the syncope as a third diagnosis.

Here’s why: “For outpatient claims, providers report the full diagnosis code for the diagnosis shown to be chiefly responsible for the outpatient services,” CMS says in Section 10.3 of Chapter 23 of the Medicare Claims Processing Manual.

“For instance,” the Manual says, “if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported. If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported.”

Therefore, in this case, the syncope is the symptom but the definitive diagnosis is the kidney failure, caused by dehydration.

FAQ 2: How Many Diagnoses Should Be Reported?

Question: Teresa Lash, CPC, COC, is seeking information on secondary diagnosis code reporting: Must we report all the current conditions that the patient has regardless of whether they are managed or treated during the observation stay? Do we only report conditions that the patients are on medications for — even if those are not managed or treated?

Answer: It is appropriate to report ongoing, preexisting conditions such as diabetes or Parkinson’s disease if the patient presents for a separate, acute condition as long as the chronic condition’s presence is relevant to or affects treatment for the acute condition. This practice not only enhances medical records and coding accuracy, but improves quality of care.

In black and white: “For outpatient claims, providers report the full diagnosis codes for up to 24 other diagnoses that coexisted in addition to the diagnosis reported as the principal diagnosis,” CMS says in Section 10.3 of Chapter 23 of the Medicare Claims Processing Manual. “For instance, if the patient is referred to a hospital for evaluation of hypertension and the medical record also documents diabetes, diabetes is reported as another diagnosis.”

Always list the primary reason for the visit first, followed by the remaining medically significant diagnoses. The existence of these “extra” diagnoses may justify additional clinical evaluation or diagnostic procedures, or they may affect the evaluation and treatment of the acute condition that caused the visit. The complexity and number of coexisting conditions dictate how detailed an examination is necessary and the complexity of medical decision-making.

If the patient is on medication for a particular condition that is in no way relevant to the current observation care, then most insurers would not require you to report it. For instance, if you see a patient for fracture care and that patient has diabetes, a history of kidney failure, and is on eyedrops to treat a scratched cornea, you would likely report the fracture, followed by the diabetes, and then the kidney failure history. The corneal abrasion would likely not be addressed, nor would it be relevant to the fracture care, and most insurers would therefore not require you to report it.

FAQ 3: Know When Infusions Are Billable

Question: Dawn Jacobs, RHIT, has a question about whether it’s appropriate to capture infusions/injections administered in the ED on surgical cases. We do not charge hydrations once the decision for surgery has been made, and the patient is NPO (nothing by mouth). Is this correct?  

Answer: The answer depends on who is performing and billing for the hydration services. If hospital staff performs the infusion or injection, then the hospital will bill it with the surgical charges.

If the ED staff performs the infusion or injection, then that emergency practice will charge for the infusion and it is separately billable on the facility side and not included in the global period for the surgery, assuming a different physician from a different practice performs the surgery.

Here’s why: If patient is in your observation unit and needs hydration but you can’t give her water because she’s awaiting surgery, then it’s your responsibility to provide hydration. The medical necessity dictates that you hydrate the patient, and you should charge for that service.