Documentation Tips

Documentation Tips: Psych Patient Disposition Decisions

Documentation Tips: Psych Patient Disposition Decisions

Managing the ED Psych Admit / Discharge / Transfer Decision

Psych patients awaiting the next step in their care present challenges for proper documentation and reporting of observation care. In this discussion we will consider the question of when physician observation care may be reported as the best reflection of the emergency physician’s evaluation and management service, whether or not the patient is registered by the hospital as a “facility obs” case.

The medical necessity of observation care is determined by the function of time as a principle diagnostic test. When a tincture of time is your principle test to determine either disposition or treatment efficacy, physician observation care is in play. Any documentation of observation should follow the reason/result

Time is a component of every ED E/M service. For observation care patients it must be the principle determinative test. That is, when all other tests and assessments are completed and disposition or efficacy is still in doubt, the work of observation care becomes the defining element of the patient’s evaluation and management.

The altered/intoxicated psych patient routinely requires physician observation care. Time is needed to metabolize the intoxicant in order to determine whether the patient is neurologically impaired separate from the intoxication. These are common obs patients.

Observation care becomes less clear when the reason for delayed disposition is unclear. When the cause is simply waiting for a bed to open up, time is certainly not a diagnostic tool at that point and obs might no longer be in play.

When the decision is delayed because the psych provider is unable to determine whether the patient can be adequately managed in the outpatient setting obs is in play. Documentation of the need for observation should address this question. Follow the usual reason/result/time format for documenting the obs service: “… and was necessary in order to determine whether the altered patient needed to be admitted/transferred to…”

Unless you have actually signed out the patient to the psych provider’s management and have no more responsibility for the patient obs is your service to report. Conversely, once you’ve made your disposition and are no longer involved, your observation period is over.

However, sign-outs rarely happen in the ED. Your patients remain your patients until they leave. You are “in consultation” with the psych provider until they have accepted the patient. Time is still the diagnostic tool that the psych provider is using and you still have some observation work to do to make the final disposition as the case is still under your direction and your management. If you’re still in charge, ED physician observation would be the appropriate method of reporting your E/M service.

When a patient awaits a bed past midnight, a new date of service occurs and payment can be made for services rendered on each date subsequent to the initial date to the extent that separate E/M services are documented. When disposed patients are housed in the ED awaiting transfer out or to the floor, it is helpful to know how the hospital classified that patient’s stay. Your chart should indicate the hospital’s admission/transfer/obs status decision.

Some facilities admit the patient once the decision is made even when the patient isn’t moved for days and still under the emergency physician’s care. In this event, the middle day services are aggregated on each date and can be reported using Inpatient Subsequent Care codes (99231-99233). Established Office Visit codes (99211-99215) can be used in lieu of the inpatient care codes if there is concern that another physician is rendering inpatient services during the patient’s stay in the ED.

If the patient has been registered as Observation status by the hospital Subsequent Observation Care codes (99224-99226) can be used to report the emergency physician’s services on middle dates after admission to obs and prior to the date of obs discharge.

Interval histories, at least once daily, reassessments and revisits while the patient remains in the ED along with any improvement or decline in the patient’s condition, new treatments/meds/decisions /plans must be documented to support separate daily E/M services. Each reassessment must be dated and timed so that services on separate dates are identifiable.

Final disposition, either discharge or admission to acute care, or for a psych transfer, does not determine whether obs care can be reported. It is the work of obs not the final destination of the patient that determines reporting.

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