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Switching from observation to admission
Tips on how to bill changes in patient status

Keywords: ICD-9 coding: billing changes in patient status from observation to admission


by Kristy Welker, CPC, CAC



Published in the March 2012 issue of Today's Hospitalist

SEVERAL READERS have sent in questions about the finer points of billing for observation and discharge services, among others. Let's take a look at those questions and my responses.

Observation services
Q: How do I bill for a patient initially admitted to observation status but then changed to inpatient status? Say the patient was admitted the night of Jan. 10 to observation and our group billed initial observation care (9921899220). But utilization management staff the next morning reviewed the case and changed the patient's status to inpatient. Do I:

1. Change the Jan. 10
The billing date for discharge services should be the day on which the actual face-to-face discharge service occurs.

bill from initial observation to an initial inpatient care code (99221-99223)?

2. Keep the initial observation code for Jan. 10 but use an initial inpatient care code for services on Jan. 11? And if so, do I have to repeat a comprehensive exam and history and document an additional history and physical for that second day?

3. Keep the initial observation care code for Jan. 10 and bill an inpatient subsequent visit for Jan. 11?


A: My answer would depend on the date the hospital reflects the status change to inpatient and what service was provided on day No. 2.

If the inpatient status was retroactively changed to Jan. 10, my answer would be No. 1: Change the bill for Jan. 10 from an initial observation to an initial inpatient visit.

If, however, the patient's status as inpatient was not changed until Jan. 11, I'd have to go with answer No. 2, based on the "Medicare Claims Processing Manual," chapter 12, section 30.6.8 ("Payment for Hospital Observation Services and Observation or Inpatient Care Services"). It states: "If the patient is admitted to inpatient status from hospital outpatient observation care subsequent to the date of initiation of observation services, the physician must bill an initial hospital visit for the services provided on that date."

However, if you did not repeat a comprehensive exam, my answer would be your No. 3. To bill an initial hospital care code (99221-99223), you are required to take a detailed history and perform an exam, at a minimum. If you do not feel that this level of service is warranted, I'd suggest using a subsequent hospital care code (99231-99233) for your services on day No. 2. But because this specific scenario is not addressed in the guidelines, check with you local carrier for its determination on what category of codes to bill.

Q: Here is a question that has all of my co-workers stumped. If a hospitalist admits a patient to observation, can a primary care physician do the discharge?

A: Only if both doctors are part of the same group practice. Only the physician—or physicians—in the same group practice who ordered the observation care can use the observation codes. According to Medicare guidelines, "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."

Review of systems
I have a question about your April 2011 article, "Making the case for a higher-level admission." In the article, you go over the best practice for documenting the review of systems (ROS).

The article states that, "All other systems reviewed and are negative" is allowed for a complete/comprehensive ROS. But you also point out that, "All other systems reviewed are negative" does not qualify. I do not understand the difference in these two statements (other than the word "and"), so please clarify.


A: You're right, that is confusing. What I meant to say was that "all systems reviewed are negative" does not qualify. To bill for a complete ROS, you must review at least 10 systems and document all pertinent positive and negative responses. The statement "All systems reviewed are negative" speaks only to those systems the physician reviewed. The physician may have reviewed only five systems, all of which were negative, but not have completed at least a 10-system review.

The point I was trying to make is that your documentation needs to make clear that you performed a complete review of systems—so "other" is the word you need to include. "All other systems reviewed are negative" would be OK.

Multiple daily visits
Q: If I admit a patient, then have to see that patient again one or more times that same day to adjust medications and talk with the family for prolonged periods, what is the best way to bill for those services? These are not critical care situations, but simply extra—and necessary— visits. Is there any way to bill them other than using prolonged services codes (99356-99357)?

A: Unfortunately not. Let me refer again to the "Medicare Claims Processing Manual," chapter 12, section 30.6.9 ("Two Hospital Visits Same Day"). It states, "pay physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase 'per day' which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service."

Discharge services
Q: One of our hospitalists wants clarification on billing for hospital discharge service, greater than 30 minutes (99239). If he spent 40 minutes on the discharge, should he document the actual time of 40 minutes? Or is it OK to state "more than 30 minutes spent on discharge" for this patient?

A: Either way would be acceptable. The patient record just needs to support that he spent more than 30 minutes.

Q: Sometimes, a hospitalist completes all necessary documentation and dictation for a discharge and conducts a face-to-face encounter with the patient. But then the discharge gets delayed, the patient is still in the hospital and the hospitalist visits the patient the next morning. Should we change the date of the discharge to that second day, even though all the discharge elements were completed the day before? Or should we bill the discharge on the first day—and possibly bill a subsequent visit the following day?

A: The billing date for discharge services should be the day on which the actual face-to-face discharge service occurs, even if the patient is actually discharged on a different date. You may bill for a subsequent visit the next day, as long as the physician can document medical necessity for that visit. Keep in mind, however, that insurance carriers may deny payment for that subsequent service, a decision you'd have to appeal to be paid.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at kristywelker@hotmail.com. We'll try to answer your questions in a future issue of Today's Hospitalist.


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