ED Coding and Reimbursement Alert

Question: A 68-year-old patient with significant airflow limitation due to obstructive chronic bronchitis is admitted to observation for acute bronchitis. The ED physician performs a comprehensive history and a comprehensive examination along with medical decision making of high complexity -- and then decides to admit the patient to observation status. Initially, the oxygen saturation is satisfactory and the physician starts the patient on antibiotics and bronchodilators by inhalation. After spending nine hours in observation (10 a.m. to 7 p.m.), the patient's condition begins to deteriorate, his oxygen saturation falls, and the ED physician decides the patient needs to be admitted to the hospital. The ED physician contacts the patient's pulmonologist for admission to the hospital. How should I code the ED physician's work in this scenario? South Carolina Subscriber Answer: On the claim, report 99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) for the initial evaluation with 491.22 (Obstructive chronic bronchitis; with acute bronchitis) appended to describe the acute bronchitis. Explanation: A physician admits a patient to observation when he is still trying to figure out whether the patient's condition requires extended treatment in an inpatient setting. This patient was admitted to the hospital after the ED physician completed the observation service; and the patient was discharged from observation so that the pulmonologist could initiate the inpatient admission. Keep in mind that Medicare requires at least eight hours of care in order to report the same-day observation codes.