Documentation Tips

Observation Care

Documentation Tips: Observation Care

Observation is a normal part of what emergency physicians do for many ED patients but it takes on another dimension of value when time becomes your principal diagnostic tool.

Observation performed by the physician in the ED does not have to be rendered in an OBS unit and might not even be defined by what is billed by hospitals as observation care. Payment for physician observation care is close to what critical care pays, as much as 27-50% more than a level 5.

Most clinicians and payers agree that observation services should be used to attempt to preclude an inpatient admission. There are two basic circumstances when physician observation is appropriate:

  1. Lack of diagnostic certainty, where a more precise diagnosis could decide inpatient admission or discharge to home, or
  2. Therapeutic intensity is uncertain, where extensive therapy has a reasonable possibility of abating the patient’s condition, and thereby prevents inpatient admission. Patients who require continued evaluation and treatment beyond the usual ED length of stay for certain presentations of chest pain, asthma, abdominal pain, renal calculi, dehydration, syncope, allergic reactions, drug ingestion/overdose, or alcohol intoxication, to name a few, might require observation.

CPT examples of medically necessary admissions that are commonly treated and released in the ED:

  • 18 m/o with 10% dehydration
  • 32 y/o female with flank pain and hematuria
  • 20 y/0 with asthma hx, with acute bronchospasm and moderate respiratory distress
  • 50 y/o with LLQ abdominal pain and elevated temperature
  • 58 y/o complaining of acute chest pain
  • 25 y/o female with suspected poly-substance abuse and/or possible psychiatric disorder, with psychotic-like presentation and markedly elevated vital signs

To bill for physician observation care time must be your principal diagnostic tool and documentation must support the reason and result of obs care. Here is a suggested template to capture required documentation:

“Patient has/has no family history of (xxx). Patient first seen at (time). Observation began at (time) and was necessary in order to determine (name the rule-out/treatment/diagnosis/mgmt decision). Upon re-evaluation, observation revealed that the patient should be (admitted/discharged/ followed up right away)” Patient discharged at (time), total time of observation (xxx) hours.

Unlike an ED Level 5 that requires 2 out of 3 Past Medical, Family, and Social History, all three are required to code the higher acuity level observation codes.  If time spent in observation is not enough to warrant coding observation care, the coder will assign the appropriate ED EM level.

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