Coding and Billing
I am often asked if there is a suggested method to compensate both the emergency physician who places a patient in observation and the one who discharges the patient from observation status, particularly when this occurs in the same day.
This is a challenge. Reporting observation is of increasing importance as EPs look for ways to accommodate time-consuming cases. In fact, Medicare now covers more hospital cases than it used to, involving about 55 percent more pay for facility obs.
But the reporting options for the physician are few. When disposition is done after midnight, two separate services on two dates can be reported - 99218-99220 for Day One, 99217 for Day Two - for payment to the group. But for same-date admission and discharge, you can give only one code, 99234-99236.
If the billing system is unable to split productivity among
contributing providers, who gets the credit?
Short answer: It depends on who does the most work, and usually that is the initiating physician. Some incentive plans compensate the disposing physician, to encourage staying with the case to completion. And that does reduce dumping of patients onto the physician just coming on shift.
But in the case of obs, the time it takes to dispose of a case depends more on the clinical circumstance than on the speed of the physician. And it usually takes more work to initiate obs than to conclude it.
A good initiating note states why obs is useful and records the plan that is to resolve the question: Should we admit or send home? Documenting that decision process is somewhat unnatural in the ED setting, since we are accustomed to moving patients quickly through diagnosis and treatment without statements about why the plan is necessary for concluding the case. But we must assure solid documentation, and offering incentives to the ordering physician would be one way to get what needs to make it into the record: the order and reason for obs along with a family history.
No incentive plan is entirely fair in every circumstance, but it makes sense that, generally, the initiating physician who documents the complete H&P and reason for obs should be credited for the work.
Providing that physician with incentive is one challenge of reporting obs. But the reward is out there. Medicare obs payment is 22 percent to 47 percent higher than for the related emergency E/M service. More hospitals will be encouraging EPs to support obs services.