ED Coding and Reimbursement Alert

Question: We just received a denial for a moderate- level observation care service (99235), and I cannot figure out why. The denial states that the service and the code choice do not match. Any idea what we might have done wrong on the claim?


Idaho Subscriber
Answer: It might have to do with your history and exam levels. In order to report even the lowest-level observation code (99234), CPT 2006 requires that the physician must:

- perform a detailed or comprehensive observation history and
- perform a detailed or comprehensive examination. Example: According to the CMS documentation guidelines, a -comprehensive- observation history means you must list three out of three elements for the patient's past/family/social history. If you were choosing an ED E/M code (99281-99285), you-d only need two out of three to qualify.

To report observation codes, make sure the doctor's notes meet requirements for both admission to and discharge from inpatient or observation care. Also include the following on any observation claim:

- length of time to determine treatment status
- timed nursing notes
- timed physician notes
- evidence of every patient interaction the physician had during the observation. (This might include time the physician talked to the patient, observed him, checked on him, re-examined him, or looked at his test results.)