ED Coding and Reimbursement Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: We see many children for dehydration in the summer months. Because many are unable to accurately evaluate their progress, our physicians want to observe them after hydration therapy to be sure there are no delayed effects from heat exposure. Should I bill for observation care and intravenous hydration? Florida Subscriber Answer: Yes, you can bill for both. In most emergency department dehydration cases, patients require only a few hours of intravenous hydration therapy (90780, Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour; and +90781, each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]). But because the patients you refer to are children, an ED physician may choose to admit them to observation. Note: Few pediatric patients are covered by Medicare, so in most cases you should apply CPT rules. See the article Medicare Versus CPT: Know the Coding Differences in this issue.

When reporting observation for Medicare beneficiaries, you should know that CMS now allows facilities to again bill for observation care (APC 0339, Observation). As a result, facility and emergency department coders are not getting the opposition they once did to rightfully report and get paid for this service provided to Medicare patients in emergency departments.

Even though E/M services provided by the same physician on the date of admission to observation are considered to be included in the observation code, hydration therapy can be separately reported and reimbursed, according to Florida's Medicare carrier. Of course, coders must determine which observation codes to assign based on the calendar dates of admission and discharge. When a physician admits a patient to observation, it should be with the anticipation that the patient will be stabilized and discharged in the next 24 hours. Therefore, if the patient is admitted and discharged on the same calendar date, report the appropriate code from the 99234-99236 series (Observation or inpatient hospital care). If a patient remains in observation for fewer than eight hours but is nonetheless admitted and discharged on the same calendar date, assign only an observation admission code (99218-99220, Initial observation care).

According to the American College of Emergency Physicians (ACEP), there should be a separate note in the patient chart that documents an order to "admit to observation status" with the time, the medical necessity for the observation admission and stay, a treatment plan, progress notes, diagnosis, and a discharge summary, plan and discharge time. Observation care codes refer to the status of the patient, not the place of service. Therefore, patients may [...]