One of emergency medicine’s top issues today results from boarding patients in the emergency department while waiting for a Psychiatric bed or transfer to an outside Psychiatric facility. Although the evaluation and management codes apply for the initial evaluation and workup (99281-99285) or provision of ED Critical Care (99291-99292), services provided on subsequent days following the initial day of treatment come under a different set of codes when certain conditions are met. If the patient’s condition requires ongoing care in the emergency department while a decision is being made regarding appropriate disposition consider the following CPT codes when the definition fits the condition:

• Initial Hospital Inpatient or Observation Care (Initial ED Visit is billed separately with modifier -25) CPT 99221-99223)
• Subsequent Hospital Inpatient or Observation Care (99231-99233)
• Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services) 99234-99236
• Hospital Inpatient or Observation Discharge Services (99238-99239)

NOTE: EACH SET OF OBSERVATION CARE ESTABLISHES TOTAL PER CODE SHOULD THE PROVIDER ELECT TO USE TIME INSTEAD OF MEDICAL DECISION MAKING TO DETERMINE THE OBSERVATION LEVEL. IF USING TIME TO DETERMINE THE OBSERVATION LEVEL, A CLEAR, CONCISE TIME STATEMENT MUST BE DOCUMENTED BY THE PROVIDER.

Although many practices follow Medicare guidance, the CPT Assistant, published by the AMA, addressed this policy in the July 2019 issue (page 10). The publication referenced that the Inpatient/Observation code set may be used to report these ED encounters. The initial day of care would be reported with 99281-99285, 99291-99292, or 99221-99223. The second day and subsequent days would be reported with a subsequent Inpatient/Observation Care code (99231-99233). If discharged, the final day of care would be reported using the Inpatient/Observation discharge day codes (99238-99239) or the Subsequent Inpatient/Observation Care codes if the patient is admitted or transferred.

As a national medical auditing company, Edelberg sees numerous examples of good and bad documentation practice so provider education is a key element to getting the coding right initially or, if the claim is denied, supporting the Observation services through detailed and thorough documentation. CMS requires a medical observation record for the patient which contains dated and timed physician orders for the observation services, nursing notes and physician progress notes while the patient is receiving observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter. In essence, the medical record for observation services should include the initial emergency department record supplemented with at least daily progress notes and a discharge summary.

The physician’s order to initiate observation status is critically important to officially “start” the Observation care process and ensure that Observation care is billed correctly. In the case of “psychiatric holds,” the ED provider is required to document the order to place the patient in observation status pending either transfer or admission to ensure that any additional days in the ED may be reported with the observation codes. To support subsequent observation care for the additional days waiting for disposition, the record should indicate that the patient is receiving active treatment from the ED provider and not simply being boarded pending transfer or admission.