星空入口

Medicare and CPT^庐 disagree on the rules for ED transfers to observation.

Ever since CPT^庐 2023 deleted the observation care codes (99218-99220), coders have faced confusion about how to report these services. That confusion is compounded by the fact that Medicare rules appear to differ slightly from the CPT^庐 guidelines on this topic.

Check these facts so you can keep bringing in reimbursement for your emergency department (ED) to observation care transfers.

Does Observation Care Coding Still Exist?

Despite the deletion of 99218-99220 from the CPT^庐 code set in 2023, the concept of observation care is still alive and well, and you can still report it. Instead of the deleted codes, you鈥檒l now report these services using the inpatient codes. For instance, initial observation care should be billed with a code from the 99221-99223 series (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination ...).

If you plan to report observation care discharge, you鈥檒l select a code from the 99238-99239 series (Hospital inpatient or observation discharge day management鈥�).

Can You Report ED Code and Observation Care?

Once you鈥檝e nailed down the appropriate observation care codes, the next hurdle to overcome involves transferring patients from the ED to observation status. The answer as to whether both codes are billable depends on whether you鈥檙e following CPT^庐 guidelines or Medicare rules.

CPT^庐 stance: Prior to 2023, coders were unable to report both an ED visit and observation care on the same date, and were instead advised to roll the code elements together to select only one code. But the changed that, stating, 鈥淲hen the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of service (eg, hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service] may be added to the other evaluation and management [E/M] service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same date.鈥�

Medicare stance: The Centers for Medicare & Medicaid Services (CMS) continue to restrict coders from billing both an ED service and an observation service on the same date. Instead, you must only report the observation care service, using an appropriate code from the 99221-99223 series. As CMS notes in , 鈥淲hen the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician鈥檚 office, nursing facility), all services provided by the practitioner in conjunction with that admission are considered part of the initial hospital inpatient or observation care when performed on the same date as the admission.鈥�

Case Study: Possible Concussion

To get a firmer handle on how to report an ED transfer to observation care, consider the following example.

A patient presents to the ED after striking their head on a pull-up bar at the gym. The ED provider examines the patient and decides they should be observed for signs of a concussion. They document straightforward medical decision making (MDM). A total of 20 minutes are spent in the ED with the patient.

The patient is then admitted to observation care, where the same provider spends another 40 minutes evaluating the patient over the course of several hours.

CPT^庐 coding: According to the CPT^庐 guidelines, you can report the following codes for this service:

• 99282-25 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making)
• 99221 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded)

Code 99282 reflects the ED visit with straightforward MDM, while 99221 represents the 40 minutes the provider spent in observation care. Modifier 25 is appended to 99282 so the payer knows that the visits were separately identifiable.

Medicare coding: According to the CMS guidelines, you must add both services together and choose just one observation code. In this case, the physician spent a total time of one hour on the patient鈥檚 care, justifying 99222 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded).

Keep in mind that not all private payers follow CPT^庐 guidelines, and some may have their own policies or use CMS rules for selecting the right observation and ED coding structure. For that reason, it鈥檚 essential to get your payer鈥檚 policy in writing before reporting these services together. That way, you鈥檒l know whether you should be rolling the code elements together and selecting just one code, or reporting both services with modifier 25 appended.

Torrey Kim, Contributing Writer, Raleigh, North Carolina