Ob-Gyn Coding Alert

Although observation care coding can be complicated and frustrating, you shouldn't overlook it. Clear documentation is the key to ensure that carriers reward your ob-gyn for his or her observation services.

Before reporting observation codes (99218-99220 and 99234-99236), you must ensure the documentation clearly indicates that the physician admitted the patient to observation status and personally saw the patient at the time of the admission. The ob-gyn's admitting order must state, "Admit to observation status." But the hospital doesn't have to have a designated "observation unit" for you to use these codes, says Lynn M. Anderanin, CPC, senior coding consultant for Healthcare Information Services LLC in Des Plaines, Ill.

In addition, all observation codes are per-diem codes. And just like other E/M codes, you can bill only one observation code per day. But unlike the inpatient and outpatient codes that you may be more familiar with, observation codes do not include a time element for counseling and coordination of care. This applies to the same-day admission and discharge codes as well.

By reviewing the following six coding scenarios, you should be able to clear up your observation care reporting and get your ob-gyn the reimbursement that he or she deserves.

1. Patients admitted to inpatient status from observation status the same day. In this case, you may report the inpatient admission code (99221-99223). The coding rules treat the observation status stay as they would any outpatient or emergency department stay. You would combine the observation care documentation with the inpatient admit documentation to determine one level of inpatient care for that day.

For example, says Brenda Dombkowski, CPC, a coding specialist at Obstetric-Gynecology & Infertility Group in Cheshire, Conn., at 8 a.m., the ob-gyn admits a pregnant patient who has been in an automobile accident to observation status, even though she does not seem to have any problems. At 4 p.m., the patient starts to bleed vaginally, and the physician immediately admits her to an inpatient unit. The ob-gyn will report 99221-99223 for his or her services that day. You will include the observation work associated with the admission when determining the inpatient admit code.

2. Patient admitted to observation status from an outpatient setting. Here, you should combine all outpatient (such as an office, emergency department, or outpatient surgery center) documentation with that for the observation care to determine one level of observation care for that day.

For instance, a patient presents with premature labor, Dombkowski says. After examining the patient and observing her in the office for a while, the physician admits her to the hospital observation unit when the labor pains do not abate. The doctor will code 99218-99220 for his or her services that day. You should base the code level on both outpatient and observation unit documentation.

3. Patient admitted to inpatient status from observation on a day subsequent to the initial observation date. In this situation, the ob-gyn may bill an initial inpatient admission (99221-99223) on that subsequent day. But he or she may not report the discharge from observation status (99217). This guideline is in keeping with the coding rule that you can report only one observation or inpatient code per day.

As an example, a patient spends a comfortable night in the observation unit. In the morning, however, her pelvic pain increases, and the ob-gyn fears an ectopic pregnancy. The doctor discharges her from the observation unit and admits her to inpatient care. You will report only the initial inpatient care code (99221-99223) for the physician's E/M services that day. You should include services provided in the observation unit that day into the inpatient care code. Again, you cannot report the observation discharge code (99217) because you can bill only one E/M code per day.

4. Patient admitted to observation status and discharged on different calendar date. On this occasion, you should report 99217 (Observation care discharge day management ) for the discharge visit.

For example, the ob-gyn admits a pregnant patient to observation Tuesday afternoon after she falls at home, Dombkowski illustrates. By Wednesday morning, she is still not exhibiting any signs or symptoms of problems, and her vital signs are stable and strong. The physician sends her home from the observation unit and bills 99218-99220 for Tuesday's observation care and 99217 for the observation discharge management on Wednesday.

5. Patient in observation formore than two calendar days. Here, you must bill the ob-gyn's services rendered on the days between the initial visit and the discharge visit using the outpatient office codes (99211-99215).

For instance, Dombkowski says, the doctor admits a pre-eclamptic patient to the observation unit from his office on Monday night for high blood pressure and reports 99218-99220 for his services that day. On Tuesday, the patient's blood pressure remains high, and the physician decides to continue observation care for Tuesday, reporting it with 99212-99215. By Wednesday morning, the patient's blood pressure has returned to a normal range, and she appears to be normal, prompting the doctor to discharge her and submit 99217 for that day's services.

6. Only the admitting physician may use the observation care codes. All other doctors seeing the patient in observation care must report their services using either the outpatient consultation codes (99241-99245) or the outpatient office codes (99211-99215).

By way of example, an internist admits a patient to observation for chest pain and notes some vaginal discharge during the examination. He asks an ob-gyn to consult on the vaginal problem. In this case, the internist will report the observation admission code, and the ob-gyn will submit the outpatient consultation code.

"This is unlike inpatient subsequent visit codes (99231-99233) when multiple physicians can use the same codes, or concurrent care, for different diagnoses the patient may have," Anderanin points out.