Documentation Is Key to Getting Paid for Observation
Published on Mon May 01, 2000
When a patient presents to the emergency department (ED) with chest pain, the pain could be a cardiac problem or just indigestion. The physician needs to order specific diagnostic tests, interpret the results and observe the patients condition over time to make the proper diagnosis. Comprehensive documentation will avoid denials of reimbursement for such observation care.
Most EDs hold patients in observation from time to time, and some departments even have specialized units dedicated to observation services (observation units, chest pain centers, critical decision units, etc.).
Because treating a patient in observation involves more physician work and time than a regular evaluation and management (E/M) visit, CPT has specific codes for these services (99218-99220, initial observation care, new or established patient; and 99234-99236, observation or inpatient hospital care [including admission and discharge services]). These codes have higher relative value units (RVUs) than the regular emergency visit E/M codes (99281-99285).
Many ED groups have had problems getting appropriate reimbursement for observation care. Last year, we started noticing that we were not getting paid for these codes, notes Tracy Bondi, CPC, coordinator of physician education and auditing for MedAmerica Billing Services in Modesto, Calif. MedAmerica Inc., an emergency medicine group with affiliates nationwide, has approximately 600 emergency physicians and physician assistants in California. One of our groups was asked by the partnership to be a test site to see if, when they beefed up the documentation requirements to bill for it, they could get reimbursed for observation.
Almost a year later, the group has been seeing appropriate reimbursement from Medicare and private payers for observation services. The group found that specific documentation and billing practices need to be followed to make sure the payers can tell that the service provided was observation as opposed to a regular ED visit, Bondi says.
CPT Requirements for Using Observation Codes
The specific observation code assigned for the visit varies, depending on the level of history, examination and medical decision-making provided and documented by the physician, just like a regular E/M visit code, says Jan Loomis, CPC, director of coding and documentation for TeamHealth West Inc., an emergency physician staffing company in Pleasanton, Calif.
The codes have the same specific documentation criteria for the detail of exam required, type of medical decision-making, etc., she notes. For example, code 99218 is for initial observation care, per day, for the evaluation and management of a patient which requires a detailed or comprehensive history, a detailed or comprehensive examination and medical decision-making that is straightforward or of low complexity.
According to CPT, observation codes should be used to report encounter(s) by the supervising physician with the patient when designated as observation status. CPT stipulates that observation care includes the initiation [...]
