Neurosurgery Coding Alert

Question: I’m new to medical coding, and I’ve been struggling with some of the evaluation and management (E/M) guidelines. I was wondering — since codes 99234-99236 require at least eight hours in observation, do I need to track the time and document it? Or do I just need to document the three key elements for the correct E/M level?

Alaska Subscriber

Answer: Yes, you should track the time and document it. Chances are, eventually, you’ll be asked for documentation of the time.

A recent CMS report indicates that Comprehensive Error Rate Testing (CERT) reviewers looked at Medicare claims for 99234 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity…). The findings indicated that most improper payments for this code were due to insufficient documentation, indicating that something was missing from the records, while other issues were due to incorrect coding.

Remember: When patients are under observation care for a period that spans between eight and 24 hours and are discharged on the same calendar date, you should choose a code from the 99234-99236 range, which includes the admission and discharge. In this situation, the documentation must meet the following three requirements, CMS says in its January 2019 Quarterly Compliance Newsletter:

• Documentation noting that the stay for observation care or inpatient hospital care involves a period between eight and 24 hours
• A notation that the billing physician was present and personally performed the services
• Documentation identifying that the order for observation services, progress notes, and discharge notes were written by the billing physician.

Reviewers from CMS’ CERT team looked at claims for 99234 that were submitted to Part B MACs between April and June of 2017. They found that many records were missing documentation that would support 99234, and in most cases, the claims were missing one or more of the following:

• A valid physician’s order that includes all required elements.
• Documentation to support the services were provided or other documentation necessary to support the code reported.
• Hospital record.
• A properly authenticated record. If a signature is missing or illegible, a signature log is required.