ED Coding and Reimbursement Alert

Question: I have an operative report in front of me that indicates two of our group’s physician’s provided observation services for the same patient on the same day. Physician 1 performed a level 2 observation service in the morning, and Physician 2 performed a level 3 observation service later that afternoon. Can I report both observations?

Indiana Subscriber

Answer: No, you cannot. Observation services are reported by the day, so would include the full calendar day. When doctors in the same ED group provide observation services to the same patient, they are deemed to be the same provider, so you’ll have to choose one code.

Typically the doctor discharging the patient gets credit for the service when the visit is shared between two emergency physicians.

In this instance, you’re probably best served to report the higher-level observation same day admit and discharge code 99236 (Observation or inpatient 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 second physician if the appropriate documentation is in place.

Although it might be tempting, coders must resist the urge to code the other observation as an E/M service. CPT^® is clear that other E/M services on the same day as admission to observation should be rolled into the observation code.