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ED Coding and Reimbursement Alert

You Be the Coder:

Discharging Patients After Overnight Observation Stays

Published on Wed May 21, 2014

Question: A patient presents in the ED with unspecified chest pain. After a complete work-up, the physician can't be sure whether the patient is having a heart attack. He decides to place the patient in observation care to determine if the patient needs admission. The physician observes the patient for 18 hours beginning at 1 p.m. on day 1, and discharges her after a normal stress test at 7 a.m. on day 2. What code(s) should I report? 

North Carolina Subscriber

Answer: You would report a pair of CPT® codes for this visit; one for the services the physician provided on day 1, and another for the day 2 care. On the claim, you should:
  •  report 99220 (Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity...) for the initial observation care the physician provided on the first day. Due to the high risk associated with chest pain, and the fact that the physician could not tell if the patient was having an acute coronary event,, a level 3 observation E/M is possible.
  • report 99217 (Observation care discharge day management...) for the services the physician provided on day two. Remember that 99217 accounts for all services the physician provided to the patient during his discharge from observation status.
  • attach ICD-9 786.50 (Chest pain, unspecified) code to 99220 and 99217 to prove medical necessity for the services.
Important: You must include the ICD-9 code for chest pain on this claim. Otherwise, the carrier will likely deny your 99220 claim for lack of medical necessity. 

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