Thursday, December 19, 2019

CPT 99224, 99225,99226, 99234, 99235 - Subsequent observation code

CPT Code Description
99224 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 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 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 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 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 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 3 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/or coordination of care with other physicians, other qualified healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 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 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 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 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 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.


Subsequent Observation Care

In the instance that a patient is held in observation status for more than two calendar dates, the supervising physician should utilize a subsequent Observation Care CPT code (99224-99226). Physicians other than the supervising physician providing care to a patient designated as "observation status" should report subsequent Observation Care.  According to the CPT codebook, “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 (i.e., changes in history, physical conditions, and response to management) since the last assessment.”

Observation Care Discharge Services

Per CPT, Observation Care discharge day management CPT code 99217 "includes final examination of the patient, discussion of the hospital stay, instructions for continuing care and preparation of discharge records." Observation Care discharge services include all E/M services on the date of discharge from observation services and should only be reported if the discharge from observation status is on a date other than the date of initial Observation Care.

Oxford follows CMS guidelines that physicians should not report an Observation Care discharge Service when theObservation Care is a minimum of 8 hours and less than 24 hours and the patient is discharged on the same calendar date.

Observation Care Admission and Discharge Services on Same Date Physicians who admit a patient to Observation Care for a minimum of 8 hours, but less than 24 hours and subsequently discharge on the same calendar date shall report an Observation or Inpatient Care Service (Including  Admission and Discharge Services) CPT code (99234-99236).

In accordance with CMS' Claims Processing Manual, when reporting an Observation Care admission and discharge service CPT code (99234-99236) the medical record must include:

** Documentation meeting the E/M requirements for history, examination and medical decision making;



Question and answers



Q: What code should be reported for a patient who continues to be in observation status for a second date and has not been discharged?
A: A subsequent Observation Care CPT code (99224-99226) should be reported in the instance a patient is held in observation status for more than 2 calendar dates. When observation discharge services are provided to the patient, report CPT code 99217 on that calendar date. For example, report CPT 99218- 99220 for a patient designated as observation on Day 1, report CPT 99224-99226 on Day 2 and finally report CPT 99217 when the patient receives discharge services on Day 3.

Q: Why are Observation Codes G0378 and G0379 not addressed in this policy ?
A: These HCPCS codes are not to be reported for physician services. These codes are to be billed by facilities on a UB-04 claim form.


Emergency department visits will be denied when billed on the same day as an observation service (procedure codes 1-99217, 1-99218, 1-99219, and 1-99220) by the same provider.


Observation Care Admission and Discharge Services on Same DatePhysicians who admit a patient to Observation Care for a minimum of 8 hours, but less than 24 hours and subsequently discharge on the same calendar date shall report an Observation or Inpatient Care Service (Including Admission and Discharge Services) CPT code (99234-99236). In accordance with CMS' Claims Processing Manual, when reporting an Observation Care admission and discharge service CPT code (99234-99236) the medical record must include:

•documentation meeting the E/M requirements for history, examination and medical decision making;
•documentation stating the stay for hospital treatment or Observation Care status involves 8 hours but less than 24 hours;
•documentation identifying the billing physician was present and personally performed the services; and
•documentationidentifying that the admission and discharge notes were written by the billing physician


Reimbursement Guidelines from Aetna Medicaid

 The order for observation must be in writing and clearly specify outpatient observation. It should also include the reason for observation and be signed, dated, and timed by the ordering physician. Verbal orders are permitted but must be documented by the individual receiving the order. The ordering practitioner must review and confirm the verbal order when they see the patient.

Applicable Codes/Conditions of Coverage

CPT Codes: 99218-99220, 99224 – 99226 Revenue Code 0762 These codes are not all inclusive. For  more reference please check LDH Fee Schedule.    On the rare occasion when a patient remains in observation  care for  3 days, the physician shall report an initial  observation  care code (99218-99220) for the first day of observation care, a subsequent observation care code (99224-99226) for the second day of observation care, and an observation care discharge CPT code 99217 for the observation care on the discharge date.


Observation: Multiple Day Codes (Admitted and Discharged on Different Calendar Days)

Day 1-The First Da
y

There are three codes for reporting the first day of observation when the discharge is on a subsequent day:
• 99218    Low complexity
• 99219    Moderate complexity
• 99220   High complexity

The Middle Days

There are three codes for reporting the middle days of observation for observation stays greater than two days:

• 99224   Low complexity
• 99225   Moderate complexity
• 99226   High complexity

The Discharge Day

There is one code for reporting the last day of observation when the discharge is on a subsequent day:
• 99217   Observation care discharge day

This code is used for the management of care on the final day, and is used in conjunction with the first day series CPT codes 99218-99220 and if applicable the middle day codes 99224-99226


No comments:

Post a Comment

Most read cpt modifiers