Home Uncategorized Answers to your questions about observation and consult codes

Answers to your questions about observation and consult codes

November 2007

Published in the November 2007 issue of Today’s Hospitalist

Based on the coding questions many of you send in, one thing is clear: Physicians get a lot of contradictory advice on how to document and bill for their services.

That confusion is understandable, given the fact that different parties “including the Centers for Medicare and
Medicaid Services (CMS) and the AMA “sometimes issue conflicting coding advice. Or the CMS proposes coding changes that don’t become final, but still become standard practice.

Here are recent questions I’ve received from readers on several areas related to hospitalist practice: how to bill for observation status; how to use the -77 modifier; when to bill consultation vs. transfer of care codes; and how to interpret E/M guidelines. Readers have also had questions about add-on codes and about which measures in the CMS’ new Physician Quality Reporting Initiative (PQRI) apply to hospitalists.

Here’s what your colleagues want to know:

Billing for observation

Q: Regarding observation status: If a patient is admitted on day 1 with an observation code, such as 99220, but that patient isn’t ready to be discharged on day 2, how should I bill for that stay?

A: According to the Medicare processing manual, you would bill the observation admit code, then use office/outpatient visit codes (99211-99215) up until the day of discharge. (You would then use the observation discharge code,
99217.) You should not use a hospital visit code because the patient has not been admitted.

However, the September 2006 issue of “AMA CPT Assistant,” a newsletter for coders, states that physicians should bill the E/M unlisted code 99499 for patients who spend more than two days in observation.

As a standard practice, I prefer following the Medicare guidelines. The unlisted codes require documentation and are difficult to get paid.

Modifier -77

Q: Can hospitalists use the modifier -77 (repeat procedure by another physician) for a repeat patient visit or encounter for a new problem the same day?

Here’s an example: I bill a 99233 for a follow-up visit in the morning, but the patient develops a new problem in the evening. Can my partner document what’s required for a 99232 and use the modifier -77 to justify two bills in one day?

A: No, it wouldn’t be appropriate to use the modifier in this case. All inpatient hospital visit descriptors contain the phrase “per day.” The code you use and the payment established for that code represent all services provided on that calendar day.

You need to select the code that represents all the services that both you and your partner provide on that date.

Consultation vs. transfer of care codes

Q: The group of hospitalists that I work with isn’t clear on when to bill for a consultation vs. a transfer of care.

The subject came up because of CMS’ clarification on surgeons’ requests for other physicians to participate in postoperative care. The clarification applies when a surgeon asks a physician or qualified nurse practitioner (NP) to manage some aspect of the patient’s condition during the postoperative period. That applies whether or not the physician or NP has been treating that patient preoperatively.

According to the CMS, the physician or qualified NP may not bill a consultation. That’s because the surgeon is not asking for an opinion or advice that he or she can use to treat the patient.

Typically, orthopedic surgeons ask us to see patients postoperatively to manage chronic conditions such as hypertension or diabetes. The hospitalists are not advising the orthopedist on how to treat those conditions, but treating those conditions themselves. I interpret that particular situation as a transfer of care based on CMS guidelines.

A: I agree. Because the hospitalist is not being asked to render an opinion but to manage a chronic condition, it would not be appropriate to bill a consult. E/M exams: How many is enough?

E/M exams: How many is enough?

Q: Here is a question we struggle with when billing: How many body areas need to be examined to fulfill a detailed exam required for a level 3 subsequent hospital visit using 1995 guidelines?

The CPT manual, which is issued by the AMA, requires “an extended examination of the affected body area(s) and other symptomatic or related organ system(s).” But the guidelines do not assign any specific number of body areas.

We’re trying to figure out what criteria to use to make sure physicians meet the guidelines for billing a 99233.

A: This question likewise drives me crazy. Neither the CMS nor the AMA’s CPT use an official point system.

The CPT advisory committee that was charged with updating the guidelines in 1996 stated that physicians need to examine between two and four body areas for an expanded exam, and between five and seven for a detailed exam.

The problem is that those 1996 guidelines were never released, so they never became official. Even so, the 1996 guidelines were widely adopted, and they are the guidelines that I use.

My advice: Decide which set of guidelines you want the physicians to follow and then document those guidelines in your compliance plan.

Source for add-on codes

Q: I was reading your comments in the May 2007 issue regarding add-on codes. Can you give me the source for your statement that physicians who are part of the same group and specialty can bill using a “CPT code and add-on codes for aggregate services provided by more than one doctor”?

A: The source is the Medicare claims processing manual (chapter 12, section 30.6.5 on physicians in group practice). The regulation states that “physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.”


Q: I have a question about the hospitalist measures related to the Physician Quality Reporting Initiative (PQRI) that were included in a news brief in the June 2007 issue.

The brief said that hospitalists would be able to report services linked to at least 12 quality measures, including measure No. 8, which is related to heart failure. On review, however, it seems that there are no inpatient services allowable for that measure. Am I interpreting the specifications for that measure correctly?

A: Yes, you are. The June news brief was based on earlier specifications that were changed.

The final PQRI measure specifications removed codes from measure No. 8 so that it no longer applies to hospitalists. (See “ New pay-for-reporting program sets its sights on individual physicians” in the July 2007 issue.) The other measures listed in the June news brief still apply to hospitalists.

However, some of the inpatient codes have been limited, and some measures now allow only discharge codes as the qualifying CPT code.

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.