Wednesday, November 30, 2011

Observation care CPT Codes 99217, 99218, 99224 –99236

a. Observation Care: CPT Codes—

• 99217 (observation care discharge day management (this code is to be utilized to report all services provided to a patient on discharge from ‘‘observation status’’ if the discharge is on other than the initial date of ‘‘observation status.’’ To report services to a patient designated as ‘‘observation status’’ or ‘‘inpatient status’’ and discharged on the same date, use the codes for observation or inpatient care services [including admission and discharge services, 99234–99236 as
appropriate.]));

• 99218 (initial observation care, per day, for the evaluation and management of a patient which requires these three key components: A detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is
straightforward or of low complexity.

Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and family’s needs. Usually, the problem(s) requiring admission to ‘‘observation status’’ are of low severity. Typically, 30 minutes are spent at the bedside and on the patient’s hospital floor or unit);

• 99219 (initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; a comprehensive examination; and medical decision making of moderate complexity.

Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and family’s needs. Usually, the problem(s) requiring admission to ‘‘observation status’’ are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient’s hospital floor or unit);

• 99220 (initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and family’s needs. Usually, the problem(s) requiring admission to ‘‘observation status’’ are of high severity. Typically, 70 minutes are spent at the bedside and on the patient’s hospital floor or unit);

• 99224 (subsequent observation care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: Problem focused interval history; problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 15 minutes are spent at the bedside and on the patient’s hospital floor or unit);

• 99225 (subsequent observation care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: An expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient’s hospital floor or unit);

• 99226 (subsequent observation care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A detailed interval history; a detailed examination; medical decision making of high complexity.

Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient’s hospital floor or unit);


• 99234 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these three key components: A detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and family’s needs. Usually the presenting problem(s) requiring admission are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit);


• 99235 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these three key components: A comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and family’s needs. Usually the presenting problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient’s hospital floor or unit);

• 99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these three key components: A comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and family’s needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit);

If another provider admits a patient into Observation Care and I provide a consult, can I bill the observation care code?

Answer:

Medicare pays for initial observation care billed by only the physician who ordered hospital outpatient observation services and was responsible for the patient during his/her observation care. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.

Who May Bill Initial Observation Care

Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring to make a decision concerning their admission or discharge.

In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in fewer than 48 hours, usually in fewer than 24 hours.

* Payment may only be made to the physician who ordered hospital outpatient observation services and was responsible for the patient during his observation care.

* A physician who does not have inpatient admitting privileges but who is authorized to furnish hospital outpatient observation services may bill these codes.

* There must be a medical observation record for the patient that 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.

* Payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient’s observation services began. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.

Example:

If an internist orders observation services and asks another physician to additionally evaluate the  patient, only the internist may bill the initial observation care code. The other physician who evaluates the patient must bill the new or established office or other outpatient visit codes as
appropriate.

Physician Billing for Observation Care Following Initiation of Observation Services

When a patient receives observation care for less than eight hours on the same calendar date, the initial observation care from CPT code range 99218–99220 should be reported by the physician. The observation care discharge service, CPT code 99217, should not be reported for this scenario.

When a patient is admitted for observation care and then is discharged on a different calendar date, the physician shall report initial observation care from CPT code range 99218–99220 and CPT observation care discharge CPT code 99217.

When a patient receives observation care for a minimum of eight hours but less than 24 hours and is discharged on the same calendar date, observation or inpatient care services (including admission and discharge services) from CPT code range 99234–99236 should be reported. The observation discharge, CPT code 99217, cannot also be reported for this scenario.

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