Pulmonology Coding Alert

You can quickly pin down which observation code (99218-99220 or 99234-99236) pair to use if you zoom in on the stay's date(s) and length. Ensure your observation claims are accurate simply by following this plan:

Before coding, be sure that the service actually qualifies as an observation, confirms Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Observation is a hospital-based outpatient service used to determine if a patient needs inpatient care. So when you're reviewing the notes, ensure claim correctness by checking the encounter specifics against this observation definition.

Observation: The pulmonologist evaluates a patient at the hospital who is experiencing shortness of breath and acute exacerbation of asthma and admits the patient to observation status to run tests and make sure the patient does not need inpatient care for pulmonary issues.

Not an observation: A patient reports to the hospital in severe pulmonary distress. The pulmonologist conducts a brief exam, attempts to stabilize the patient, and admits the patient to the intensive care unit (ICU) immediately to begin active treatment.

Next, you'll need to revisit the encounter notes to see how many calendar days the observation service spanned. If the patient is in observation for more than one calendar day, you'll choose from the 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components ...) code set for the first day of care, confirms Cheryl Allard, RHIT, clinical data analyst at Saint Francis Medical Center in Grand Island, Neb.

Use these codes "for all the care rendered by the admitting physician on the date the patient was admitted to observation," Allard says.

Example: Consider the earlier scenario featuring the patient with shortness of breath and congestion; let's say that the pulmonologist admits the patient to observation at 9 p.m. Wednesday. The pulmonologist orders a spirometry test, the results of which were not normal. The patient is kept overnight for monitoring. Notes indicate the pulmonologist performed a mid-level observation service.

For the pulmonologist's Wednesday services, you'd report 99219 (... a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity) with 786.05 (Shortness of breath) and 493.22 (Chronic obstructive asthma; with [acute] exacerbation) appended to 99219 to represent the patient's symptoms.

For Medicare payers, and payers that follow federal guidelines, you must confirm that the patient spent at least eight hours in observation before reporting 99234-99236."When a patient is admitted for observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218--99220, shall be reported by the physician," states the Medicare Claims Processing Manual. "The observation care discharge service, CPT code 99217, shall not be reported for this scenario."

For example, a Medicare patient is admitted to observation at 6 a.m. and discharged at 10:23 a.m. one Friday. In this scenario, you'd select a 99218-99220 code, depending on the specifics of the encounter.

Remember: You must document a "two-prong" encounter when using 99234-99236, clarifies Pohlig.These codes represent two codes rolled into one, for both admission and discharge. Therefore, make sure the pulmonologist has documented two face-to-face encounters before using this code.