ED Coding and Reimbursement Alert

'Middle day' observation codes are game changers for patients in observation 3+ days.

Coders need to understand the new 99224-99226 observation codes soon, as reporting the "middle days" of observation services lasting three days or more will change on Jan. 1, 2011. To illustrate how to use the 99224-99226 observation codes, consider this detailed clinical example courtesy of Michael Granovsky, MD, CPC, FACEP, president of MRSI, an ED coding and billing company in Woburn, Mass.

A 62-year-old patient with dyspnea and chest pressure presents to the ED at 8 p.m. Saturday. The physician admits the patient to observation at 11 p.m. Saturday. During the patient's stay in the observation unit, the physician obtains a comprehensive history, which reveals increasing exertional dyspnea over the last three days, known coronary artery disease, a myocardial infarction (MI) two years prior and 2 episodes of congestive heart failure (CHF) in 2009.

The physician performs a comprehensive multi-system examination; the EKG reveals non-specific ST changes inferiorly, CHF, and labs demonstrate a high normal CK with a normal index. The physician orders initiation of oxygen, nitrates, and diuretics. The second set of cardiac enzymes are negative, but the patient is still dyspneic and fluid overloaded. Notes reveal a detailed interval history and detailed exam, as well as several progress notes, on Sunday. The physician also orders more cardiac enzymes, a repeat chest x-ray and an electrocardiogram (EKG); the physician also continues therapy through periodic reassessments. The patient remains in observation thorough Sunday, and with the aggressive use of medications, has a dieresis of three liters of fluid.

After the patient's dyspnea ceases, serial EKGs reveal no real change and continued cardiac marker results are negative, the patient is discharged Monday; the discharge notes include a formal observation discharge, a final exam and plan to follow up with his regular physician. Final diagnosis is chest pain and CHF .

Under CPT 2011 guidelines, you'll report the following for this service:

• 9220 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) for Saturday's observation service
• 99226 (Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: 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) for Sunday observation service
• 99217 (Observation care discharge day management ...) for Monday's observation service and discharge
• 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for each appropriately documented EKG
• 428.0 (Heart failure; congestive heart failure, unspecified) appended to 99220, 99226, 99217 and 93010 to represent the patient's CHF
• 786.59 (Symptoms involving respiratory system and other chest symptoms; chest pain; other) appended to 99220, 99226, 99217 and 93010 to represent the patient's chest pain.