ED Coding and Reimbursement Alert

Question: A patient presents in the ED with unspecified chest pain. After a complete workup, 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 care on day 2:
 
- 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 whether the patient was having an acute coronary event, a level-three  observation E/M is possible.
 
- report 99217 (Observation care discharge day management ...) for the services the physician provided on day 2. Remember that 99217 accounts for all services the physician provided to the patient during his discharge from observation status.
 
- attach ICD-9 code 786.50 (Chest pain, unspecified) to 99220 and 99217 to prove medical necessity for both of 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.