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Mental Health FAQ

  • What CPT code should be reported for the initial evaluation and management of a mental health patient in the Emergency Department?

    Recommendations
    Answer

    If a patient is evaluated in the emergency department and discharged, admitted or transferred to another facility, the appropriate codes are the ED E/M codes 99281-99285. If the patient's clinical condition and the provider’s interventions and time meet the requirement for critical care, critical care codes 99291-99292 may be reported.

    If the patient's condition will require ongoing short-term treatment, assessment, and reassessment in the emergency department, while a decision is being made regarding appropriate disposition (i.e. admission or transfer for inpatient psychiatric care versus discharge); or if the patient will be monitored in the emergency department pending the availability of an inpatient psychiatric bed, observation codes 99218-99220 (initial observation care w/discharge on a different day)  or 99234-99236 (admitted and discharged to and from observation on the same date) may be reported.

    Answer

    If a patient is evaluated in the emergency department and discharged, admitted or transferred to another facility, the appropriate codes are the ED E/M codes 99281-99285. If the patient's clinical condition and the provider’s interventions and time meet the requirement for critical care, critical care codes 99291-99292 may be reported.

    If the patient's condition will require ongoing short-term treatment, assessment, and reassessment in the emergency department, while a decision is being made regarding appropriate disposition (i.e. admission or transfer for inpatient psychiatric care versus discharge); or if the patient will be monitored in the emergency department pending the availability of an inpatient psychiatric bed, observation codes 99218-99220 (initial observation care w/discharge on a different day)  or 99234-99236 (admitted and discharged to and from observation on the same date) may be reported.

  • What CPT code(s) should be used to report services provided to a patient monitored in the Emergency Department over multiple days while waiting for an inpatient psychiatric bed to become available?

    Recommendations
    Answer

    Per CPT Assistant July 2019 (page 10), the observation code set may be used to report these encounters. The initial day of care would be reported with 99281-99285, 99218-99220 or 99291 as indicated in FAQ 1.  The second day (and 3rd day, and 4th day, etc.) would be reported with a Subsequent Observation Care code (99224-99226). The final day of care would be reported with the Observation Discharge Day code (99217).

    Answer

    Per CPT Assistant July 2019 (page 10), the observation code set may be used to report these encounters. The initial day of care would be reported with 99281-99285, 99218-99220 or 99291 as indicated in FAQ 1.  The second day (and 3rd day, and 4th day, etc.) would be reported with a Subsequent Observation Care code (99224-99226). The final day of care would be reported with the Observation Discharge Day code (99217).

  • What documentation is needed to report observation codes for these extended types of cases?

    Recommendations
    Answer

    Using the observation codes for extended psychiatric ED stays is a new concept. However the documentation requirements for observations services have not changed. Per CPT, observation codes are used to report services to patients designated/admitted as “observation status” and include the initiation of observation status, supervision of the care plan for observation and performance of periodic reassessments.

    To report observation services, CMS states "there must be a medical observation record for the patient which contains dated and timed physician's orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter." Practically speaking, the medical record for observation services should include the initial emergency department record supplemented with at least daily progress notes and a discharge summary.

    A key factor in CPT and CMS language is the physician’s order to initiate observation status.   This initiates observation care and cannot be done retroactively at the end of a long ED stay to change the billing from ED codes to observation codes. In the case of “psychiatric holds” the ED provider should document an order to place the patient in observation status pending availability of an inpatient psych bed to make sure that any additional days in the ED may be reported with the observation codes.

    To support reporting subsequent observation care for the additional days the patient is monitored in the emergency department, the record should indicate that the patient is receiving active treatment from the ED provider and not simply being boarded pending transfer.

    Answer

    Using the observation codes for extended psychiatric ED stays is a new concept. However the documentation requirements for observations services have not changed. Per CPT, observation codes are used to report services to patients designated/admitted as “observation status” and include the initiation of observation status, supervision of the care plan for observation and performance of periodic reassessments.

    To report observation services, CMS states "there must be a medical observation record for the patient which contains dated and timed physician's orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter." Practically speaking, the medical record for observation services should include the initial emergency department record supplemented with at least daily progress notes and a discharge summary.

    A key factor in CPT and CMS language is the physician’s order to initiate observation status.   This initiates observation care and cannot be done retroactively at the end of a long ED stay to change the billing from ED codes to observation codes. In the case of “psychiatric holds” the ED provider should document an order to place the patient in observation status pending availability of an inpatient psych bed to make sure that any additional days in the ED may be reported with the observation codes.

    To support reporting subsequent observation care for the additional days the patient is monitored in the emergency department, the record should indicate that the patient is receiving active treatment from the ED provider and not simply being boarded pending transfer.

  • What would constitute treatment?

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    Answer

    Examples of active treatment include providing suicide watch precautions, crisis intervention, managing acute and/or chronic medical conditions, medication management, implementing psychiatric consultation recommendations and/or other counseling of the patient or family, and coordinating care with other providers or facilities to expedite transfer/admission. Interval re-evaluations and response to treatment should be documented at least daily.

    Answer

    Examples of active treatment include providing suicide watch precautions, crisis intervention, managing acute and/or chronic medical conditions, medication management, implementing psychiatric consultation recommendations and/or other counseling of the patient or family, and coordinating care with other providers or facilities to expedite transfer/admission. Interval re-evaluations and response to treatment should be documented at least daily.

  • What are the E/M documentation requirements for Initial Observation Care codes?

    Recommendations
    Answer

    E/M

    History

    Exam

    MDM

    Typical Time

    99218

    Detailed

    Detailed

    Straight Forward

    30 Mins

    99219

    Comprehensive*

    Comprehensive

    Moderate

    50 Mins

    99220

    Comprehensive*

    Comprehensive

    High

    70 Mins

    These codes are used to report the initial day of care when the patient’s stay extends past midnight. They may be reported with observation discharge code 99217 when the patient is discharged after midnight.

    * Note that a comprehensive history for observation codes requires at least one element from each of the three components of past, family and social history; while one element from two of the three components are necessary for ED codes.

    Answer

    E/M

    History

    Exam

    MDM

    Typical Time

    99218

    Detailed

    Detailed

    Straight Forward

    30 Mins

    99219

    Comprehensive*

    Comprehensive

    Moderate

    50 Mins

    99220

    Comprehensive*

    Comprehensive

    High

    70 Mins

    These codes are used to report the initial day of care when the patient’s stay extends past midnight. They may be reported with observation discharge code 99217 when the patient is discharged after midnight.

    * Note that a comprehensive history for observation codes requires at least one element from each of the three components of past, family and social history; while one element from two of the three components are necessary for ED codes.

  • What code is reported for Observation Care Discharge?

    Recommendations
    Answer

    99217 – On the day the patient is discharged home, admitted as an inpatient or transferred to another facility, the provider who managed the patient’s final day of observation care should report 99217 for services provided on the discharge day.

     

    These services include a final exam, discussion of the observation stay, follow-up instructions, and documentation of discharge summary.

    Answer

    99217 – On the day the patient is discharged home, admitted as an inpatient or transferred to another facility, the provider who managed the patient’s final day of observation care should report 99217 for services provided on the discharge day.

     

    These services include a final exam, discussion of the observation stay, follow-up instructions, and documentation of discharge summary.

  • What are the E/M documentation requirements for the Same Day Observation Admission and Discharge Codes?

    Recommendations
    Answer

    E/M

    History

    Exam

    MDM

    Typical Time

    99234

    Detailed

    Detailed

    Straight Forward

    40 Mins

    99235

    Comprehensive*

    Comprehensive

    Moderate

    50 Mins

    99236

    Comprehensive*

    Comprehensive

    High

    55 Mins

    Answer

    E/M

    History

    Exam

    MDM

    Typical Time

    99234

    Detailed

    Detailed

    Straight Forward

    40 Mins

    99235

    Comprehensive*

    Comprehensive

    Moderate

    50 Mins

    99236

    Comprehensive*

    Comprehensive

    High

    55 Mins

  • What are the E/M documentation requirements for Subsequent Observation Care Codes?

    Recommendations
    Answer

    E/M

    History

    Exam

    MDM

    Typical Time

    99224

    Interval Problem Focused

    Problem Focused

    Low

    15 Mins

    99225

    Interval Expanded Problem Focused

    Expanded Problem Focused

    Moderate

    25 Mins

    99226

    Interval Detailed

     

    Detailed

     

    High

    35 Mins

    For the subsequent observation codes, CPT indicates the physician should document an interval history. Interval history is commonly defined as an update on the status of the patient since the last encounter.  The E/M guidelines stipulate when documenting an "interval" history it is not necessary to record information about the past, family or social history.

    Per CPT, “All levels of subsequent observation care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient’s status (changes in history, physical condition, and response to management) since the last assessment.”

    The documentation for subsequent observation care codes requires two out of three of the E/M elements composed of history, exam, and MDM.  (As opposed to 3 out of 3 elements required for the ED E/M codes and initial observation care codes.) General consensus in the coding community is that MDM should be one of the elements used to determine the level of service reported.

    Answer

    E/M

    History

    Exam

    MDM

    Typical Time

    99224

    Interval Problem Focused

    Problem Focused

    Low

    15 Mins

    99225

    Interval Expanded Problem Focused

    Expanded Problem Focused

    Moderate

    25 Mins

    99226

    Interval Detailed

     

    Detailed

     

    High

    35 Mins

    For the subsequent observation codes, CPT indicates the physician should document an interval history. Interval history is commonly defined as an update on the status of the patient since the last encounter.  The E/M guidelines stipulate when documenting an "interval" history it is not necessary to record information about the past, family or social history.

    Per CPT, “All levels of subsequent observation care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient’s status (changes in history, physical condition, and response to management) since the last assessment.”

    The documentation for subsequent observation care codes requires two out of three of the E/M elements composed of history, exam, and MDM.  (As opposed to 3 out of 3 elements required for the ED E/M codes and initial observation care codes.) General consensus in the coding community is that MDM should be one of the elements used to determine the level of service reported.

  • The observation care codes include time as one of the E/M components. This is not typically part of the documentation and coding process in emergency medicine. How is time used as a factor for determining an observation care code?

    Recommendations
    Answer

    CMS specifies that the duration of the visit is an ancillary factor and does not control the level of the observation service to be billed unless more than 50 percent of the floor time is spent providing counseling or coordination of care.

    CPT states that when counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family, then time may be considered the key or controlling factor to qualify for a particular level of E/M services.

    The physician should document relevant details of the encounter with a description of the coordination of care and/or content of the counseling provided to support medical necessity. The code selection is based on the total time spent during the patient encounter, not just the counseling time.

    The counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit. Time spent counseling the patient or coordinating the patient’s care after the patient has left or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.

    The duration of counseling or coordination of care provided on the floor may be estimated but that estimate, along with the total duration of the visit, must be documented when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.

    Answer

    CMS specifies that the duration of the visit is an ancillary factor and does not control the level of the observation service to be billed unless more than 50 percent of the floor time is spent providing counseling or coordination of care.

    CPT states that when counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family, then time may be considered the key or controlling factor to qualify for a particular level of E/M services.

    The physician should document relevant details of the encounter with a description of the coordination of care and/or content of the counseling provided to support medical necessity. The code selection is based on the total time spent during the patient encounter, not just the counseling time.

    The counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit. Time spent counseling the patient or coordinating the patient’s care after the patient has left or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.

    The duration of counseling or coordination of care provided on the floor may be estimated but that estimate, along with the total duration of the visit, must be documented when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.

  • What RVU’s are associated with the Subsequent Observation codes 99224-99226, and Observation Discharge Day code 99217?

    Recommendations
    Answer
     

    CPT

    RVU

    CY 2020

    Low complexity Subsequent OBS

    99224

    1.12

     $ 40.42

    Moderate complexity Subsequent OBS

    99225

    2.06

     $ 74.35

    High  complexity Subsequent OBS

    99226

    2.95

     $106.47

    Observation Discharge Day

    99217

    2.06

     $ 74.35

    Answer
     

    CPT

    RVU

    CY 2020

    Low complexity Subsequent OBS

    99224

    1.12

     $ 40.42

    Moderate complexity Subsequent OBS

    99225

    2.06

     $ 74.35

    High  complexity Subsequent OBS

    99226

    2.95

     $106.47

    Observation Discharge Day

    99217

    2.06

     $ 74.35

  • Does this apply to facility billing?

    Recommendations
    Answer

    Payment policies can vary from payer to payer. Some insurers may arbitrarily and/or inappropriately deny a claim if it exceeds certain time limits. You are advised to contact your local payers for their policies on billing observation services.

    Answer

    Payment policies can vary from payer to payer. Some insurers may arbitrarily and/or inappropriately deny a claim if it exceeds certain time limits. You are advised to contact your local payers for their policies on billing observation services.

  • Where can I get more information on billing observation?

    Recommendations
    Answer

    CPT Assistant, July 2019, page 10
    ACEP Observation Physician Coding FAQ: Observation Physician Coding
    ACEP Observation Facility Coding FAQ: ACEP Observation Care Payments to Hospitals

    Answer

    CPT Assistant, July 2019, page 10
    ACEP Observation Physician Coding FAQ: Observation Physician Coding
    ACEP Observation Facility Coding FAQ: ACEP Observation Care Payments to Hospitals

Updated December 2019

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (972) 550-0911, ext. 3233 or dmckenzie@acep.org.

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