Written By: Compliance Blogger
Did you know that consultations performed by a physician or qualified Non-Physician Practitioner (NPP) while the patient is in observation care is reported as an outpatient visit selecting codes 99202 – 99205 for a new patient and 99211-99215 for an established patient?
- Only initial observation services performed by the primary care physician (i.e., physician of record) are reported using the initial observation care CPT codes (new or established patient) 99218-99220.
- Subsequent observation care is reported per day using CPT codes 99224-99226. These codes include review of the medical record, results of diagnostic studies and response to change in patient status since the previous physician assessment.
Background on Patient Hospital Status & Medicare Guidelines
Billing and coding of physician services is expected to be consistent with the facility billing of the patient’s status as inpatient or outpatient. The determination of an inpatient or outpatient status for any given patient is specifically reserved to the admitting physician. However, when coding the professional claim, things can become confusing when the hospital changes the patient status from inpatient to outpatient.
As stated in the CMS Publication IOM 100-04, the Medicare Claims Processing Manual, Chapter 1, Section 50.3.2: “In cases where a hospital utilization review committee determines that an inpatient admission does not meet the hospital’s inpatient criteria, the hospital may change the beneficiary’s status from inpatient to outpatient and submit an outpatient claim (bill type 13x or 85x) for medically necessary Medicare Part B services that were furnished to the beneficiary, provided all of the following conditions are met:
- The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;
- The hospital has not submitted a claim to Medicare for the inpatient admission;
- A physician concurs with the utilization review committee's decision; and
- The physician's concurrence with the utilization review committee's decision is documented in the patient's medical record.
When the hospital has determined that it may submit an outpatient claim according to the conditions described above, the entire episode of care should be billed as an outpatient episode of care. The section further gives the instruction: “When the hospital submits an outpatient claim for services furnished to a beneficiary whose status was changed from inpatient to outpatient, the hospital is required to report Condition Code 44 on the outpatient claim.”
Coding Guidance & Tips
The following Healthcare Common Procedure Coding System (HCPCS) codes are reported by hospitals when billing observation services whether separately payable or packaged:
G0378 Hospital observation services, per hour
G0379 Direct referral for hospital observation care
- These codes are not payable under the physician fee schedule.
Physician of Record
Initial observation services performed by the primary care physician (i.e. physician of record) are reported using the initial observation care CPT codes (new or established patient) 99218-99220.
*Remember – 99218-99220 still follow the 1995 and 1997 evaluation and management (E&M) documentation guidelines.
- Evaluation and management services performed by the supervising practitioner and provided on the same date and in sites that are related to the initiation of observation care are not separately reported.
- Observation services initiated on the same date as the patient's discharge are reported by the primary care physician as observation care CPT codes 99234-99236.
- Observation discharge service is reported using CPT code 99217 if the discharge is on a date other than the initial date of observation care. Procedure code 99217 includes all services provided to a patient on the day of discharge from outpatient hospital observation status.
- For patients receiving observation services who are admitted to hospital inpatient status on the same date, the primary care physician should report only the initial hospital care CPT codes 99221-99223 with the AI modifier.
**Note - It is not appropriate to report a discharge from outpatient hospital observation care (CPT code 99217) when a patient is admitted to hospital inpatient status on the same day.
Consultations Performed During Observation Status
Evaluation services (consults) requested of other physicians and qualified NPPs while the patient is in observation care are reported as office or other outpatient visit CPT codes 99202-99205 or 99211-99215.
- Remember – the new 2021 E&M outpatient documentation guidelines apply, using time or medical decision-making to select level of service.
Abide by the Centers for Medicare & Medicaid Services (CMS) Split/Shared E&M Visit Rules
On May 26, 2021, CMS published a notice regarding split/shared evaluation and management visits and critical care services. This notice is in effect through December 31, 2021. Click Here to read this notice and monitor your Medicare Administrative Contractor (MAC) website for updates.
A shared or split visit is defined as a visit in which a physician and other qualified health care professional(s) jointly provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of services for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and other qualified health care professional(s) assessing and managing the patient on the date of the encounter is summed to define total time. Only distinct time should be summed for shared or split visits (i.e., when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).
Until such time as CMS promulgates a final rule regarding split (or shared) E&M visits and critical care services, the agency will limit review to the applicable statutory and regulatory requirements for purposes of assessing payment compliance.
Are your claims being denied? Review coding, guidelines and documentation standards. If everything is compliant, then appeal the denial.
Just because the admission status indicates “inpatient,” it is important for coders to verify whether the patient status was changed and could be outpatient or observation bed status. Most coders will know whether the provider is the physician of record or consulting. If there is any question regarding the role of the billing provider, the coder must query the physician to ensure codes are selected from the appropriate category or verify the patient status with the hospital.
Appeals Management – apply expertise to create an effective appeals management system. If your physician is routinely subjected to denied claims, consider enrolling in the Certified Outpatient Clinical Appeals Specialist online training program. Cost of certification is included in tuition.