General Surgery Coding Alert

Many general surgery coders have no trouble following CPT rules for hospital observation services, but they need to be familiar with the intricacies of both the CPT rules and Medicares observation policy to get optimum benefits from observation care. Since the inception of Medicares observation coding policy, which conflicts with CPT guidelines, there has been some confusion regarding the appropriate way to bill for observation care. Reserve Observation Codes for Special Cases Typically, general surgeons use observation care codes for emergency department (ED) cases, particularly for situations involving trauma. Physicians often admit patients who have had traumatic accidents to observation status until he or she is sure that no additional injuries manifest or to ensure that any treatment provided is adequate for a patients problem, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.

In addition, surgeons may admit patients to observation care from the ED who present with a nonspecific complaint such as abdominal pain, says M. Trayser Dunaway, MD, FACS, a general surgeon in private practice in Camden, S.C. For example, the surgeon may see the patient and decide that he or she should be admitted to observation overnight for monitoring and to check lab results. Surgeons may also admit a patient to observation overnight for monitoring after certain surgical procedures, such as laparoscopic cholecystectomy, Dunaway says. However, keep in mind that observation care after same-day surgical procedures is always bundled into the procedure and cant be separately billed, Bucknam says. Know What Observation Status Means There are certain criteria you must follow in observation care coding. For instance, according to Empire Medicares (New Jerseys Part B carrier) local medical review policy, "Only the physician who admitted the patient to hospital observation and is responsible for the patient during his stay in observation may bill the hospital observation codes." All other physicians who see that patient must bill the appropriate office or other outpatient consultation codes. The global surgery fee includes payment for most hospital observations. According to Medicare, payment is made for observation services in addition to the surgical package only if two criteria are met: The hospital observation service justifies using modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period), -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or -57 (Decision for surgery)

The hospital observation service meets all the criteria for the hospital observation code billed.

In addition, the physician must include a medical observation record for the patient that includes dated and timed admitting orders concerning the patients care, along with nursing notes and progress notes prepared [...]