ED Coding and Reimbursement Alert

Question: Is it required that an examination be documented in order to bill code 99217 (Observation care discharge day management...) on the date of observation discharge?

Ohio Subscriber

Answer: There are some terms used in CPT^® that can influence code choice if their grammatical intention is misinterpreted. A common one is the use of "requires" versus "includes." Use of the word "requires" means that you must perform the indicated elements in order to use the code. "Includes" means that if you use the code the indicated elements are not separately reportable.

With respect to E/M services, there are some common "requires" statements. In the description of some of the E/M services the language is... evaluation and management of a patient, which "requires" these three key components...; meaning those E/M services cannot be reported without all 3 components. Or other E/M codes, "which requires at least 2 of these 3 key components" so only 2 of the elements are required but less than 2 in unacceptable.

If we search CPT^® for "includes" statements the first one found is:

Family History

A review of medical events in the patient's family that includes significant information about:

• The health status or cause of death of parents, siblings, and children
• Specific diseases related to problems identified in the Chief Complaint or History of the Present Illness, and/or System Review
• Diseases of family members that may be hereditary or place the patient at risk

It seems unreasonable to expect that all of those bulleted elements must be in the chart to be considered a documented family history.

The next includes statement is in relation to the HPI: "This includes a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem(s)." Again not all of the elements are required on each chart.

Another example of "includes" in the descriptor of codes that we commonly use in the ED is "This includes local anesthesia and chemical or electrocauterization of wounds not closed" in the instructions for simple laceration repairs. Those elements are not required in order to bill 120xx codes but are not separately billable if codes 120xx are reported

The description of 99217 does not use a "requires these components" statement. According to CPT^® and CPT Assistant^® 99217 includes the elements:

• Final examination of the patient,
• Discussion of the hospital stay,
• Instructions for continuing care,
• Preparation of discharge records

These elements are not separately billable if performed on the same day as 99217 is reported.

There is certainly a requirement for discharge note or summary to show physician involvement on the final day of care but there is no content requirement for that note. CMS statements on other E&M issues would imply that there must be some kind of provider/patient encounter on the discharge day (meaning simply reviewing the chart is not acceptable) but performance or documentation of a physical exam is not a requirement of 99217.