Answers to your questions on observation and discharge codes

Answers to your questions on observation and discharge codes

February 2008

Published in the February 2008 issue of Today’s Hospitalist

WHAT CODE SHOULD YOU USE to bill a preop evaluation? And do you need to report time spent on discharge services if you spend less than 30 minutes?

Those are just two of the questions I’ve received from readers since the last time I answered questions. Here are some readers’ questions “with answers “on documentation and coding.

Related resource: 40+ Collected Coding Tips

Q. As the primary hospitalist for a patient who needs a preoperative evaluation, is there a specific CPT code I should use?

A. There currently is no special CPT code for a preoperative evaluation. Instead, pick a code depending on whether you are acting as the admitting physician or a consultant.

If you do the history and physical to admit the patient, then you would use one of the admission codes (99221-99223). But if another physician requests a consultation, you should bill a consultation code (99251-99255).

Otherwise, you’ll have to use a subsequent visit code (99231-99233) to bill for your service.

Q. How do I bill if one hospitalist provides a 99223-level admission and then another hospitalist in the same group sees the patient later that same day? Does the second physician simply provide his service for free?

A. According to the CMS manual, you should combine the history, exam and medical decision-making of both physicians and bill one level of service for the group on any given date.

The exception is when a patient becomes critical and a hospitalist returns to the floor and/or bedside to render critical care for more than 30 minutes. In that case, you would bill for two separate, identifiable services “and affix a -25 modifier to the first service.

Q. We continue to have problems with documenting the “place of service” for observation service codes 99234-99236. If we use POS 21, which denotes an inpatient service, the carrier tells us that the patient was not an admitted inpatient. But if we use POS 22, which denotes an outpatient service, the carrier tells us that we didn’t request preauthorization for the inpatient. Any suggestions?

A. I would let the physician’s documentation drive the appropriate place of service. If a patient was in observation, then use POS 22. But if the patient was actually admitted and discharged on the same day, then go with POS 21.

If you have to provide back-up for payers, I’d suggest quoting from the section on 99234-99236 in the CPT manual. (If you’re using the CPT 2008 Professional Edition, see the language on page 13.)

Q. Say I see a patient and appropriately bill a 99232 for a subsequent middle level visit, but then I also do an arterial sample (36620) the same day. What do I write on the encounter form that I submit to billing: 99232 and 36620? Or 99232-25 and 36620?

A. The second choice is more appropriate: 99232-25 and 36620.

Q. Please explain why I need to include a patient’s diagnoses with the CPT codes that I’m billing.

A. Payers want to see two types of documentation. One is the type of service that the physician provided, which is reported by the CPT or procedure. The other is the reason or medical necessity for that service, which is the ICD-9 or diagnosis code.

When billing for a preop evaluation, choose a code depending on whether you are the admitting physician or a consultant.

To justify the CPT code that you’re billing, be sure to document the proper history, exam and medical decision-making in the patient record.

As for diagnosis codes, be as specific as possible. For instance, if you are billing for a complication, such as neuropathy, in a diabetic patient or hypertension in a patient with chronic kidney failure, you would choose different codes than if you were treating a patient who had just neuropathy or hypertension.

Also remember to code and report any stable diagnoses that you are treating. List the more acute conditions first, followed by the stable conditions being managed.

Q. Do physicians need to document time when billing 99238 for discharge services if they spend less than 30 minutes? I have searched both Medicare materials and the Internet, and I can’t find any information on this.

A. No, you don’t need to include time when spending less than 30 minutes on a 99238.

Q. In your December 2007 column LINK TO, you state that physicians need to make only one comment for past medical, family and social history. However, in the box accompanying the article, you state that a complete past, family and social history needs two to three comments. Is the correct answer two or three?

A. For a complete past, family and social history, hospitalists need to make just one comment in each of these categories for a total of three comments. These could encompass consultations, initial hospital care and hospital observation codes.

For subsequent visits, physicians need to include only an interval history. No past, family or social history is needed.

Q. As a hospitalist at an academic center, I leave most of the documentation to residents. As attendings, we of course include an addendum or attestation, but how should I handle discharge billing if a resident does the discharge? Do I have to provide an attestation, and how am I supposed to bill for resident time?

A. When residents do a discharge, attendings still need to provide an attestation. (See “What should you include in an attestation, below.) As for billing residents’ time, you should include that time in the total time spent on discharging the patient, and bill accordingly.

Tamra McLain is an independent coding consultant in Southern California. E-mail her LINK your documentation and coding questions to, or send a fax to 888-202-1601. We’ll answer your questions in a future issue of Today’s Hospitalist.

What should you include in an attestation?

Attendings working with residents need to document attestations to show that they have reviewed and approved a resident’s care and treatment plans.

Here are samples of approved attestations from the Centers for Medicare and Medicaid Services:

  • “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
  • “I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
  • “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia.”
  • “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”