Orthopedic Coding Alert

Question: Our orthopedist admitted a patient as observation status. He handwrote a history and physical (H&P) form, but his documentation doesnt meet the criteria of 99218, so he wants to charge a new patient code (99201) instead. Is this correct?

Delaware Subscriber
 
 

Answer: If the orthopedists documentation fails to meet the criteria for the lowest-level observation code (99218), you should instead report 99499 (Unlisted evaluation and management service) for Medicare patients and submit a copy of the physicians chart notes with
your claim.
 
You may be able to report 99218-52 (Reduced services) to non-Medicare insurers, but this depends on your private insurers guidelines. 
 
Your bigger problem seems to be poor documentation. If your physicians routinely under-dictate their chart notes, your practice is probably throwing away a lot of reimbursement.
 
Anytime you admit a patient to observation status, the record should indicate when you admitted him or her, some rationale for the observation (for example, Patient is admitted to observation due to suspicion of head
injury), the physicians orders for the specific nursing care, diagnostic tests, etc., to be performed while the patient is in observation, and notes regarding the patients status during periodic reassessments.
 
The history and physical used to determine the level of observation can take place either during the observation service or during the initial emergency department visit, but CPT rules do not allow you to report a regular E/M code and an observation code on the same date of service.
 
According to CPT, When observation status is initiated in the course of an encounter in another site of service (e.g., hospital emergency department, physicians office, nursing facility) all evaluation and management services provided by the supervising physician in conjunction with initiating observation status are considered part of the initial observation care when performed on the same date.