Published in the June 2011 issue of Today’s Hospitalist
READERS STILL HAVE PLENTY OF QUESTIONS about the ins and outs of billing inpatient services. Here are answers to your questions about how to code observation, initial hospital care and discharge services.
Q: I am often asked to consult on Medicare patients in observation. Because Medicare eliminated outpatient consultation codes (99241-99245), what code should I use for these patients? Should I use outpatient service codes (99201-99215)? And do we need to use different codes for new and established Medicare patients in observation?
A: The codes you refer to (99201-99215) are for office or other outpatient services. These codes are further based on whether the patient is new (99201-99205) or established (99211-99215). (A new patient is de- fined as one who has not been seen by you or anyone within your group and your same specialty in the last three years.) Use these codes for Medicare patients ” as long as neither you nor anyone in your group admitted the patient to observation, but have been subsequently asked to participate in that patient’s care.
For private carriers that have not followed Medicare’s example and eliminated consult codes, you can still use outpatient consultation codes (99241-99245), if your opinion was sought during a patient’s care. If you were asked to treat a non-Medicare patient, use the office or other outpatient service codes (99201- 99215).
As to your last question: Observation codes 99218- 99220 (initial observation), 99234-99236 (observation admit and discharge on the same date) and 99217 (observation discharge) do not have a new or established patient component. These are the codes to use if you are the physician admitting and discharging a patient in observation.
Q: Say that I admit a patient at 10 p.m. by phone but do not see her until the next day at 7 a.m. The patient is discharged that second day at 4 p.m. after a chest pain work-up. Do I bill a same-day observation same-day admit and discharge code (99234-99236) because the only patient encounters took place on that day? Or do I bill an observation admission code (99218-99220) for the first day and a discharge code (99217) for the next day, even though I had no face-to-face encounter with the patient that first day?
A: Because your face-to-face encounters with the patient for both the initial visit and discharge occurred on the same day, bill an observation same-day admit and discharge code (99234-99236).
But note that the Centers for Medicare and Medicaid Services (CMS) hasn’t given specific guidance on this issue. That means that Medicare carriers have come up with their own interpretations, and different carriers have different opinions. If your carrier can’t give you clear directions, your group should determine a policy and follow it consistently. Be sure to document that policy as part of your compliance plan.
Initial hospital care codes
Q: I read your column in the April issue of Today’s Hospitalist ("Making the case for a higher-level admission") and need some further clarification.
My coder tells us to use the initial hospital care codes (99221-99223) only if we are asked to see a patient to address a specific condition or answer a specific medical question about that patient. This would entail an original assessment with a history and physical and, possibly, one or two follow-up visits to address tests we may order.
But if we are simply being asked to follow a particular condition such as diabetes in a patient admitted for surgery, the coder claims that the initial hospital care codes would not apply. Instead, she says to use the appropriate subsequent hospital care code (99231-99233).
A: According to Medicare guidelines, all physicians should report an initial hospital care code for their initial visit to an inpatient; nothing in Medicare guide- lines spells out any need to address a specific question. Refer to the 30.6.10A consultation services section of the "Medicare Claims Processing Manual."
Q: I have two questions about billing discharges. Both relate to being able to charge for time spent on discharge services the day before an actual discharge.
Here’s the first scenario: For a patient being discharged to a nursing home the next day, I often do the discharge paperwork and dictation the day before, especially for a complicated patient. I typically round on the patient and complete that day’s note, deciding on that day’s E/M code, and then work up the discharge. My partner will round the next day on the patient and complete the discharge. While my partner can certainly charge for the discharge (99238), can he or she bill the higher-level discharge (99239), given that I spent more than 30 minutes pre- paring for the discharge the day before? I’d, of course, document the amount of time I spent on discharge preparation in my dictation.
Here’s scenario two: I am going to discharge the patient tomorrow. I spend 20 minutes today doing discharge work (and document it), then another 20 minutes tomorrow discharging the patient. May I add the times from both days together and charge a 99239 because the total time spent is more than 30 minutes? Or should I charge only a 99238 because I spent only 20 minutes on the actual day of discharge?
A: Discharge planning often begins before the actual day of discharge. In both these scenarios, you can add the previous day’s efforts in discharge preparation to your total discharge time. However, you can bill the discharge code only under one physician’s name and for the calendar date that the patient is actually discharged.
Just be sure that you don’t include in your discharge code any time that might overlap with other services. Discharge time should not, for instance, include any time spent rounding on the patient the previous day. Also, cumulative time cannot include services rendered by residents or housestaff.
Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at firstname.lastname@example.org. We’ll try to answer your questions in a future issue of Today’s Hospitalist.