In the Emergency Department (ED), the evaluation and management of mental health patients require careful consideration of CPT code selection and accurate documentation. This guide aims to provide clarity on the appropriate codes to report for initial evaluations, extended stay cases, and discharge services. Additionally, it emphasizes the necessary documentation requirements to support the reported codes.

Initial Evaluation and Management:

For mental health patients evaluated in the ED and subsequently discharged, admitted, or transferred to another facility, the appropriate codes to report are the ED E/M codes (99281-99285). The appropriate ED E&M code will be based on the MDM driven by the complexity of the patient’s condition and the provider’s interventions. In cases where critical care is provided, the critical care codes (99291-99292) may be reported if the criteria are met.

Extended Stay Cases:

In situations where a mental health patient needs ongoing short-term treatment, assessment, and reassessment in the ED while awaiting disposition or transfer for inpatient psychiatric care, the Inpatient/Observation codes (99221-99223) may be utilized. These codes reflect initial inpatient or observation care, with the discharge day management codes (99238-99239) or the admitted and discharged on the same date codes (99234-99236) reported if the patient is discharged or transferred.

Multiple-Day Monitoring in the ED:

When a patient is monitored in the ED over multiple days while waiting for an inpatient psychiatric bed to become available, the Inpatient/Observation code set remains applicable. On the initial day, the appropriate code from the initial Inpatient/Observation Care series (99281-99285, 99291-99292, or 99221-99223) is chosen. For subsequent days, the subsequent Inpatient/Observation Care codes (99231-99233) should be reported, indicating ongoing care and monitoring. Finally, if discharged, the Inpatient/Observation discharge day codes (99238-99239) or the subsequent Inpatient/Observation Care codes (99231-99233) are reported, depending on the patient’s disposition.

Documentation Requirements:

Accurate documentation is essential to support the reported codes for observation services. The medical record should include the following:

1. Dated and timed physician’s orders regarding observation services
2. Progress notes prepared by the physician during the observation period
3. Discharge planning, including follow-up instructions and coordination with other providers when applicable.
4. Daily progress notes documenting active treatment, response to treatment, and evaluation of the patient’s condition

It is crucial to ensure that the physician’s order to initiate observation status is documented at the appropriate time and not retroactively applied at the end of a prolonged ED stay. This is particularly important for cases involving “psychiatric holds.” To support subsequent observation care reporting, it is necessary to document that the patient is actively receiving treatment from the ED provider rather than being merely boarded pending transfer.

Active Treatment and Reevaluation:

Active treatment for mental health patients in the ED can encompass various interventions, including suicide watch precautions, crisis intervention, management of acute or chronic medical conditions, medication management, implementation of psychiatric consultation recommendations, counseling of the patient or family, and coordination of care with other providers or facilities. Regular interval reevaluations and response to treatment should be documented daily.

Level of Medical Decision Making and Total Time:

When reporting Inpatient/Observation E/M codes, both the level of medical decision making (MDM) and total time spent by the physician or qualified healthcare provider (QHP) on the day of the encounter are considered. While time is not typically documented to determine E/M levels in emergency medicine, it may be necessary in observation coding. Physicians’ documentation of the total time spent may meet the time requirements specified in the E/M code level descriptor.

Inpatient/Observation Care Discharge:

For the discharge of a mental health patient from inpatient/observation status, the provider who managed the patient’s final day of care should report 99238 or 99239. These codes encompass the necessary elements of the discharge service, including the final examination, discussion of the hospital stay, instructions for continuing care, and preparation of discharge records. Notably, an MDM level is not required for these codes, and they are solely based on time spent with the patient.

Conclusion:

Proper coding and documentation play a vital role in accurately capturing the management of mental health patients in the Emergency Department. By adhering to the guidelines outlined in this guide, Emergency Medicine Specialists can ensure accurate coding, reduce coding errors, and support appropriate reimbursement for the services provided.