ED Coding and Reimbursement Alert

If you have questions about documenting observation services, you need to be familiar with this advice.In August 2011, CMS released Transmittal 2282, Pub 100-04 Medicare Claims Processing, dealing with clarification of many aspects of Evaluation and Management Payment Policy. The transmittal contains direction related to critical care, and observation services. Guidance is also provided for the reporting of certain E/M services following the CMS elimination of payment for all consult codes with the exception of telehealth consultations, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, an ED coding and billing company in Bedford, MA.

Pay Attention to Observation Orders and Progress NotesClear and reinforcing directions regarding key Observation documentation components are included. The Transmittal states, "There must be a medical observation record for the patient which contains dated and timed physician's orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the [...]