Gastroenterology Coding Alert

Hint: Do not use discharge code 99217 in all observation situations.

Sometimes deciding on what observation code to use can be a challenge, especially because you have to look into two sets of this type. One set (99234-99236) pertains to the care provided on a single calendar date, while another set concerns care that spans two calendar dates (99218-99220).

Find out the criteria for observation codes' use for physician services by debunking these 3 fallacies.

Fallacy 1: Observation Services Support Extended Inpatient Care

You would want to make sure -- first and foremost -- that the service performed by your gastroenterology qualifies as an observation. The physician should opt for observation services to potentially prevent a lengthy inpatient admission. For instance, an observation status is appropriate when:

The encounter lacks diagnostic certainty, where a more precise diagnosis could decide admission or discharge;

The patient's condition needs extensive therapy in order to possibly be abated.

Example: The gastroenterology sees a patient at the hospital who experiences abdominal pain and nausea with vomiting. The physician admits the patient to observation status to run tests and make sure the patient does not need inpatient care for gastric issues.

Fallacy 2: Documentation, Just Another Paperwork

The physician's notes on the encounter would tell you how many calendar days the observation service lasted.

Consider the earlier scenario. Say the gastroenterologist admits the patient to observation at 9 p.m. on Wednesday. The physician orders blood tests to check the patient's enzyme levels and performs a hydrogen breath test (91065, Breath hydrogen test [e.g., for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal gastrointestinal transit]) to check for any traces of bacterial overgrowth. The results of both tests turn out normal. The physician keeps the patient overnight for monitoring. Her notes indicate a level two observation.

Code it: You would report the Wednesday services with 99219. 99219 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of moderate severity.). Additionally, another key component of coding multi-calendar date observation codes is reporting 99217 (Observation care discharge day management [This code is to be utilized by the physician to report all services provided to a patient on discharge from "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient CareServices (including Admission and Discharge Services, 99234-99236 as appropriate.)]) on the date of discharge service. Link 789.00 (Abdominal pain unspecified site) and 787.01 (Nausea with vomiting) to both CPTs to describe the patient's symptoms.

Use 99218-99220 for all the care rendered by the admitting physician on the date the patient was admitted to observation, says confirms Cheryl Allard, RHIT, clinical data analyst at Saint Francis Medical Center in Grand Island, Neb.

For the documentation requirements, the CMS Claims Processing Manual indicates that a physician can bill the initial observation care codes, provided he completes a medical observation record for the patient. This record should contain dated and timed admitting orders of the physician, and reflect the care the patient gets while in observation, nursing notes, and progress notes prepared by the physician while the patient was in observation status.

"This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter," according to the article Observation -- Physician Coding published by the American College of Emergency Physicians on its website.

Fallacy 3: Same-Day Observation Codes Call For a Discharge Code

How about your gastroenterologist admits a patient to observation status and discharges him on the same calendar date? Then you'd report 99234-99236. In this case, you wouldn't have to code the 99217 discharge code. CPT allows the use of 99217 "if the discharge is on other than the initial date of 'observation status'," as specified on the code's descriptor.

Same-day observation services 99234-99236 involve documenting the time of the visit in hours (with a minimum of eight hours documented on the same calendar date, also referred to as the 8-hour rule).

Example: A gastroenterologist admits a patient to the hospital for observation because of fever and cramps in the right upper abdomen. Based on the observation, the gastroenterologist performs an endoscopic retrograde cholangiopancreatography (ERCP) and removed a foreign object from the bile duct. The gastroenterologist discharges the patient that afternoon.

If your physician provided level-two observation service before the ERCP, you would report:

• 43269 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of foreign body and/or change of tube or stent) for the ERCP; 99235 for the observation;
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to  99235 to show that the observation and the ERCP were separate services;
• 789.01 (Abdominal pain right upper quadrant) attached to 43269 and 99235 to prove medical necessity for both services.