ED Coding and Reimbursement Alert

Question: We bill for emergency physicians who have just had added a Chest Pain Center to their ED. Therefore they are using the observation codes in that area. Can you help us with the following scenario?

Patient is admitted to observation on Monday at 2:00 pm and remains there until Tuesday at 11:00 am when the patient is admitted to the hospital. The inpatient admission is not made by the emergency physician, but by another physician that has taken over the care shortly before 11:00 am. The emergency physician has treated and documented care for the second day until the care was taken over. We realize that we will bill the initial day of observation but are unclear about what should be billed on the second day. Since our physician did not admit the patient to the hospital, are the only appropriate codes the outpatient hospital/office codes? Any suggestions you have would be appreciated.

Ohio Subscriber

Answer: This case confuses the decision to admit to the hospital with the decision to discharge from observation. For someone else to make the decision to discharge from observation (either by admitting to the hospital or sending them home) there must at some point be a transfer of care or the equivalent of a discharge from observation.

The first calendar day services are represented by the 99218-99220 observation code set. The crux of the question is how to represent the care on the second day. The physician documented an encounter with the patient and the patient was then admitted to the hospital and became an inpatient.

For 99217 (Observation care discharge day management...), the code was set up to recognize the work performed in discharging a patient that has had a lengthy stay, including final exam of the patient, discussion of the observation stay, documentation a record preparation, etc. The wording for the introduction to the observation discharge services section states "includes" not "requires." The concept here is that all those mentioned services are bundled into 99217. However, it does not say that they are all absolutely required. CPT® frequently uses the "required" concept when there is a list of items that need to be accomplished in order to use a certain code; such as 99285 (Emergency department visit for the evaluation and management of a patient which requires these three key components...).

Since the wording is "includes" followed by a list of services, and the physician had a well-documented encounter, you could justify using 99217 to represent the discharge services. The admitting physician would be using an initial inpatient admission code and he could not use the discharge from observation code as this would be bundled into the work when reporting 99221-99223 services.

Note that the discharge codes 99217, 99238 (Hospital discharge day management; 30 minutes or less), and 99239 (...more than 30 minutes) have no delineated history and physical exam specific documentation requirements. However, the 99238 and 99239 code descriptors codes are time based with 99238 used to report hospital discharge day management for 30 minutes or less and 99239 when the discharge process goes beyond 30 minutes.

Anything that happened with this patient after midnight constitutes the initial nature of the discharge service. So, assuming that the chart documentation records that the emergency physician performed some interaction with the patient's case, such as a progress note, a final physical exam, and next steps in the care, the work of a discharge service was done on the second calendar date.