Home By the Numbers Billing observation: initial care and consults

Billing observation: initial care and consults

Plus, pay attention to attestation dates

January 2018

MY SEPTEMBER 2017 COLUMN, “The ins and outs of observation billing,” prompted some more questions on how to bill for observation services. In this month’s column, we’ll review two additional queries about observation billing.

Observation codes
Which codes should we use for a patient placed in observation by the night hospitalist at 11 p.m., then discharged at 8 a.m. the next morning?

That’s simple: If a patient is placed in observation on one calendar date and discharged on another, report an initial observation care code (99218–99220) for the first day, then the observation discharge code (99217) on the calendar date of the discharge.

Only the physician attending in observation can bill observation codes.

If, however, the night hospitalist had placed that same patient in observation on the same calendar day that the patient is discharged, you should use one of the codes for same day admission and discharge: 99234– 99236.

Observation consult
I do coding for a multispecialty practice that employs both hospitalists and specialists. When a patient is placed in observation and a specialist consult is called, what code set do I use to bill the consult: 99201-99205 (new patient office visit) or 99212-99215 (established patient office visit)? I’m under the impression that new patient guidelines do not pertain to observation. But I have had only one claim denied when I billed a 99203—and I believe that denial was due to the fact that I also billed a 99236 (same day admission and discharge).

When a specialist is called in to see a patient in observation, that service should be billed using the new patient E/M codes (99201-99205), as long as that patient has not been seen by anyone in that specialist’s group and of the same specialty within the last three years.

Doctors have the same documentation requirements for a 99203 billed for an observation patient as they would in an office or hospital outpatient clinic. And remember: Only the physician attending in observation can bill the codes in the observation section of the CPT manual.

Inpatient admissions
Our night hospitalists admit patients between 5 p.m. and 8 a.m. Typically, they see (and bill for) patients who arrive before midnight. But when they do admit someone after midnight, they bill an initial visit (99221-99223). The day hospitalist then sees that patient later that same morning. But when that day visit is on the same calendar day as the admission, we’re not sure what to charge for it.

As you know, Medicare considers physicians from the same group practice and the same specialty as a single physician. If a patient is admitted after midnight and seen later that same day by a second hospitalist, the medical necessity of that second visit could be called into question. If you routinely have hospitalists who work days rounding on these patients, think about how you want to handle this scenario.

Both initial and subsequent visits are paid on a per-diem basis. When physicians from the same group and specialty bill two services on the same date, it will be viewed as a single visit. You can combine the documentation of both hospitalists, then select the appropriate level of service for that visit—but only if both visits are medically necessary. That’s a very important caveat.

Make sure the physicians clearly reflect medical necessity in their documentation. You’ll find more about this scenario in the Medicare Claims Processing Manual, 100-4, chapter 12, section 30.6.9, subsection B.

Attestation dates
Does the date of an attending’s attestation need to be the same as the date the resident saw the patient? Or if the attestation date is different than that of the resident’s service, does the attestation have to specifically state the date on which the teaching physician saw the patient? I’m billing for a service provided by a resident, but the attestation is dated two days later and it is unclear when the attending physician actually saw the patient.

If the supervising physician is not physically present for the key or critical components of the resident’s encounter with the patient, the supervising physician must independently see the patient, perform those elements and document the findings. This information is documented in the Medicare Claims Processing Manual, chapter 12, section 100.

If the teaching physician is physically present for those key or critical components, the teaching physician must still personally document his or her presence and attest to agreeing with the resident’s evaluations and plan of care.

The situation you describe—a note generated by the teaching physician that’s dated days after the actual encounter the resident documented—could be risky. It certainly does call into question whether the teaching physician was physically present during the visit. I recommend that you check with your legal department about how to report a service when there is a discrepancy between the date of service the resident provides and the date listed on the attestation statement signed by the supervising physician.

Sue A. Lewis, RN, CPC, PCS, has more than 40 years of health care experience.



Published in the January 2018 issue of Today’s Hospitalist
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November 2022 3:11 pm

When a specialist is called in to see a patient in observation, should we use the POS 11 or 22 with office visit codes?

Last edited 1 year ago by Jesse
February 2018 9:51 am

When hospitalists are asked to come evaluate a Medicare patient in the ER to determine admission, should the hospitalist bill ED CPT codes or 99211-99215 (office visit, established patient) or 99201-99205 (office visit, new patient)?

January 2018 9:40 am

Per CPT® Assistant, September 2006, Volume 16, Issue 9, pages 8-12; Only the physician performing the services of admitting the patient to observation status may report the initial observation care code. For observation encounters provided by physicians other than the admitting physician, other E/M codes are reported, as appropriate. For example, if a consultation is requested by the physician admitting the patient to observation status, then the consulting physician would report the consultation by using the office or other outpatient consultation codes (99241-99245). If the patient remains on observation the next day, even if discharged later that day, and the… Read more »