ED Coding and Reimbursement Alert

Along with observation set expansion, new manual opens up options for ultrasound on extremities

In 2011, coders will have a new option when reporting the middle day of observations that last longer than normal; also, ultrasound (US) will get more specific as CPT doubles your choices for extremity US.

Check out this expert advice on how CPT additions will affect your ED coding starting on Jan. 1, 2011.

New Codes Offer Benefit of Clarity

Before 2011, coding for the "middle days" of an observation service was a problem, says Jill Young, CPC, CEDC, CIMC, principle with Young Medical Consulting LLC in East Lansing, Mich.

"Although not the norm, there are situations where a patient is admitted to observation and remains in that status for three or more days," Young explains.

The CPT 2011 E/M section addresses these middle days, with these new codes scheduled for inclusion:

• 99224 -- Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; 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 patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.
• 99225 - ... an expanded problem focused interval history; an expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are  rovided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.
• 99226 - ... a detailed interval history; a detailed examination; Medical decision making of high 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 patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit. 

When to use: "If you had a patient admitted to observation on July 1 and discharged from observation on July 3, the problem for coders was how to bill for July 2," Young says. In 2011, you'll use 99224-99226 for July 2.

99224-99226 Stamp Out Insurer Variances

"Historically there has been some confusion about how to report the middle day for those cases when an observation period transcends three calendar days. The introduction of the new CPT codes resolves that dilemma," explains Michael Granovsky, MD, CPC, FACEP, president of MRSI, an ED coding and billing company in Woburn, Mass.

Prior guidance for middle days created some confusion and led to several different policies, such as the Spring 1993 edition of CPT Assistant, which instructed coders to "use the unlisted evaluation and management service code (99499, Unlisted evaluation and management service) to report these services."

Payers often took their own path, however, when setting policy on "middle day" observation coding. "Previously it was a carrier's prerogative," Young says Payers would often call for 99499; some carriers, however, preferred 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: ...) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient, ...). (For a detailed clinical example using the 99224-99226 observation codes, see "Use This Expert Scenario to Get a Grip on 99224-99226 Situations" on page XXX.)

Check US Status to Use New US Codes

CPT 2011 will also roll out a more specific set of extremity US codes, Granovsky confirms.

2010: When the physician performed US of the extremity with real time image documentation, you would report 76880 (Ultrasound, extremity, nonvascular, real time with image documentation).

2011: CPT scraps 76880 and replaces it with:

• 76881 (Ultrasound, extremity, nonvascular, real-time with image documentation; complete)
• 76882 (Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific).

Consider this scenario from Granovsky: Example: On Jan. 2, 2011, a 59-year-old diabetic presents with pain and swelling over the left leg. Following an expanded problem focused history and physical exam, the physician performs a limited US to determine the presence of an abscess. The physician then discharges the patient with  prescriptions for antibiotics and pain medication; final diagnosis is leg cellulitis. In 2011, you will report the following:

• 76882 for the limited US
• modifier 26 (Professional component) appended to 76882 to show that you are only coding for the physician's work (unless the group owns the ultrasound equipment; then you can leave modifier 26 off the claim).
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity...) for the E/M
• 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 99283 to show that the E/M and the US were separate services
• 682.6 (Other cellulitis and abscess; leg, except foot) appended to 76882 and 99283 to represent the patient's cellulitis.