Wiki ED Admit to OBS

[tfrick2]

This may sound like a dumb question, but I don't do much coding for observation services. When reviewing OBS charts for diagnosis codes, do you look at the discharge summary as well? For example, a patient who goes to the ED for chest discomfort, dyspnea and right-sided facial numbness, is admitted from the ED to OBS and followed by a hospitalist for three days before discharge. The patient had Neurology and Endocrinology consultations while in observation, as well as a cardiac echo to rule out issues there. Would you look at the discharge summary when trying to capture diagnoses for the ED and OBS charges?

Thanks in advance!
Tracy

 

[thomas7331]

In theory, if you are coding for the individual physician services, you would code based on the information in the particular note and include only the conditions that were treated or affected treatment by that provider because your coding just represents the work of the provider. If you're coding for the hospital, however, the emergency and observation services are usually all going to be included on a single claim, so in that case it would be appropriate to use the entire record, including discharge notes. In practice though, your organization should give you some guidelines on this because there can be some variances on how this is done based on billing systems, local payer requirements, hospital internal policies, etc.

 

[jimbo1231]

ED to Obs

Just a side bar. You mentioned admit from ED to Observation and billing for ED and Observation. If patient is admitted from the ED to Obs on the same day you would only be billing for Observation if greater then 8 hours.

Jim

 

[tfrick2]

I am coding for the facility, so it sounds like the discharge summary does need to be used. I code profee as well, so I think that's what's throwing me off.

Regarding the ED and OBS charges, OBS would override ED even with different doctors? Is that because it's the facility side, which is all-encompassing? Does the OBS need to be over 8 hours on that DOS, or is that total observation time?

I really appreciate both of you helping me with this!

Tracy

 

[dinaraju06]

Just a side bar. You mentioned admit from ED to Observation and billing for ED and Observation. If patient is admitted from the ED to Obs on the same day you would only be billing for Observation if greater then 8 hours.

Jim

Hi Jim,

I have a case in which patient stayed in ed for 4 (12/17/2017 16:57-21:07)hours and then the patient was transfered to obs and stayed until 12/19/2017.The same doctor has seen the patient in both ED and Obs.He do have documentation for ED but dont have documentation for Obs for the inital day.How can I code this?Please help