A Reader asked the question: After 10 frustrating years in the outpatient world, I have finally seen the light and joined a hospitalist group. I need some SERIOUS 411 on coding and appreciate your witty and informative blog. I have NO CLUE how to code obs patients. Please advise!!!
Emily, I'm glad you asked. Understanding observation status is VERY EASY. First of all, it should not be up to you on whether a patient is a full admit or an observation status. It takes experience to get a feeling on who is full admit and who is observation. The utilization review people of the hospital carry around huge books with thousands of rules that Medicare and private insurance companies use to determine whether a patient meets inpatient criteria. If they say they don't, the patient is observation status. Do what they say so everyone gets paid. You have to make sure your CPT® medical coding status as a physician matches the status of the patient by the hospital. For example, if the patient is observation status by the hospital, and you are billing inpatient codes, you will get denied. Once your billing is in line with the hospital's status it is really quite easy.
Read this very carefully, because understanding the following few paragraphs will show you the light on hospital billing. It really is VERY EASY to understand. You ONLY have three possible scenarios to worry about.Emily, I'm glad you asked. Understanding observation status is VERY EASY. First of all, it should not be up to you on whether a patient is a full admit or an observation status. It takes experience to get a feeling on who is full admit and who is observation. The utilization review people of the hospital carry around huge books with thousands of rules that Medicare and private insurance companies use to determine whether a patient meets inpatient criteria. If they say they don't, the patient is observation status. Do what they say so everyone gets paid. You have to make sure your CPT® medical coding status as a physician matches the status of the patient by the hospital. For example, if the patient is observation status by the hospital, and you are billing inpatient codes, you will get denied. Once your billing is in line with the hospital's status it is really quite easy.
- Inpatient status
- Observation status that crosses over the magic midnight hour
- Admit/Discharge Same Day (Does not cross over the magic midnight hour)
For #2. Observation status that crosses over a midnight hour. That means if you admit a patient observation at 11:59 PM and discharge them 8 hours later at 8:00 am, they qualify for the admit observation codes 99218, 99219, 99220. For purposes of learning the requirements necessary to pass an audit by the coding police, this is the easy part. The following rules in coding documentation apply: 99218 (low level obs)=99221 (low level admit), 99219 (mid level obs)=99222 (mid level admit), and 99220 (high level obs)=99223 (high level admit). So if you learn how to code the three full admit codes, you just pick the equivalent level in the observation codes. And the easiest part of all is that there is only one possible discharge code you can use: 99217. There is a slight trickiness to using observation stays that go past 2 midnight stays. For example lets say you bring a patient into the hospital observation status on June 1st at 11:59 pm. You can bill a (99218- 99220) for June 1st. Lets say the following calendar day, June 2nd at 8 am, you are doing rounds and you determine the patient is not stable for discharge. You can elect to keep them there under observation status (Medicare allows up to 48 hours of observation care). Or you can do a full hospital admission (if they meet criteria determined by your utilization folks). If you elect to keep them observation, in this case, on June 2nd, you would bill them outpatient clinic codes (99212-99215). Since the patient is not technically admitted, you cannot bill the inpatient subsequent care codes (99231-99233). On the following day, June 3rd, the third calendar day you would bill the observation discharge code 99217 when they are discharged. If you decide to make the patient a full admission on June 2nd, technically, you can do another complete H&P and bill a new full admit code (99221-99223) on June 2nd, in addition to the June 1st observation code (99218-99220). However, I rarely do this because I don't want to go through all that hassle. I usually write an order to change the status to full admission from admission and then change my original June 1st observation code (99218-99220) to a full admit code (99221-99223) and then bill an inpatient follow up visit on June 2nd (99231-99233). Once a full admit, you use the inpatient follow up codes until discharge, at which point you pick either the less than 30 minutes (99238) or greater than 30 minutes (99239)
#3 The admit/discharge same day (99234, 99235, 99236). This is even easier. If the patient is admitted and discharged on the same calendar day (meaning they do not stay past a midnight) then these are the only possible codes you can use. Nobody will pay you for the full admit codes (99221-99223) or the observation codes (99218-99220). And just like the other observation codes, you determine which level based on the requirements of coding documentation. And, once again, here's the easy part, 99221=99218=99234, 99222=99219=99235, 99223=99220=99236. That's why you only need to learn just the rules for the full admit codes 99221-99223 and you have all the others learned as well. Remember the 99234-99236 are used when the patient is admitted and discharged on the same calendar day. For example admitted June 1st at 8 am and discharged June 1st at 4 pm. Medicare rules state that the patient must be in the hospital for at least 8 hours or nobody will get paid. So you may want to round on them last if they are going to go home the same day. One rare scenario that I run into is the occasional drug overdose on a ventilator that I admit using the critical care codes 99291, 99292. Sometimes the patient will improve very quickly, I can extubate and discharge on the same day. In this case, I would keep my critical care code but I wouldn't bill a discharge code because there is no discharge code that would suffice. A critical care code will probably be audited on a patient that is discharged the same day, but I say, so what. I did the work so well, they got well enough to leave the same day. I'm not going to screw myself out of billing appropriately just because the patient got well quickly.
One other thing to look out for. As a hospitalist, you will get consulted to see surgical patients that are ASC (ambulatory surgery center) status. Basically the observation codes for surgeons. These are usually overnight stays. If you get consulted to see a patient in ASC or observation status, make sure you bill outpatient consult codes 99241-99245. And if you see the patient the next day, bill the outpatient clinic codes 99212-99215. If you see a patient in the ER and decide they don't need to be admitted, bill the outpatient consult codes 99241-99245. If you see the patient as an inpatient consultant, bill an patient consult code as CPT 99251, 99252, 99253, 99254, or 99255.
You can see much more in my free lectures on medical billing and coding.
You can see much more in my free lectures on medical billing and coding.
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Nicely done. Your compliance officer should be proud.
ReplyDeleteAWESOME! Thank you so much for the detailed answers. You rock.
ReplyDeleteAre you sure you can change observation to full admit, from the beginning? I don't think this is in line with CMS regulations since an admission order cannot be backdated.
ReplyDeleteI checked with my coding people. When a change from full admit to observation is made retro actively, they document a "code 44" which involves some paper work on their end to indicated to CMS that the change has been made. I have no idea what a "code 44" is, but apparently it works as they say they haven't had a problem using this documentation to get it approved.
ReplyDeleteHappy
There is now a crack down on going back and back dating the observation full admission issues. For now, we have been told not to back date an order, to just write the change to be initiated on the day the order is written.
ReplyDeleteI have read that this "code 44" is not the complete answer to fixing the inpatient to observation care senerio. Have you heard this? Could you elaborate on what you know about billing a patient in the senerio: Patient is admitted from ER at 11:00 PM on day 1, night doc see's patient and bills inpatient initial care visit. Then at 10 AM (technically day 2)when the case managers come around, the patient is decided to not qualify for inpatient status, and is changed to OBS. Day doc does rounds and bills OBS code. How should that billing look? Can you bill a 99223 for day 1, and then just start billing OBS codes, and would it be a 99218, or an outpatient code?
ReplyDeleteanony 10:03. In your example, I would change my admit code to a (99218-99220). When the claim gets submitted by our hospital, they will submit an observation claim, not an admission claim and hopefully Medicare will pay for the first calendar day. That's the code 44 issue. I have another post on that here.
ReplyDeletehttp://thehappyhospitalist.blogspot.com/2009/09/is-patient-inpatient-status-or.html
If the hospital doesn't submit an inpatient DRG, then my inpatient admit code will get denied without a doubt. The hospital status and the physician status must align.
Thank you so much for your fast, and detailed response. I think you're blog is offically more reliable than any of the other people I've asked about this. It's been an issue at our hospital for almost a month now. Thank you!
ReplyDeleteHello Happy Hospitalist - We are struggling with the following situation: Doctor A sees pt at 11 am and bills Observation level 2 for pt with chest pain. Doctor B comes on night shift and sees pt has ruled out for ACS and discharges pt to home at 10 pm. This is admit/discharge same day to Observation service. How does Doctor A know what to bill since he/she doesn't know at time of admission whether pt will be discharged same calendar day or not by second provider, Doctor B?
ReplyDeleteSKA. In same day admit discharge codes we always give credit to the admiter with the 99234-99236 codes. The discharger gets no credit but it should wash out over time. We simply change the admit code to an admit/discharge same day code
ReplyDeleteThanks for the feedback, Happy Hospitalist. This situation doesn't happen that often, but we were perplexed as to how to deal with it when it does.
ReplyDeleteYou didn't answer the oBV to IP question. You answered the IP to OBV issue with the code 44. If the patient is initially OBV and then goes to IP, you stated that you do not then do another H&P, you simply bill the original H&P as the "hospital admit," rather than OBV admit. You say that you write an order to change the status from the beginning. According to all guidelines I've read, you can not do this. You cannot backdate status. Once OBV services are provided, that cannot be then changed to IP. The code 44 applies to changing a pt to OBV from IP status. It doesn't work the other way around. I hope your charts don't get selected.
ReplyDeleteanon. When an a patient is changed from obs to inpatient, I change my bill from obs to inpatient. I have checked with my hospital coding people and they confirmed that is correct.
ReplyDeleteI don't write an order to change it from the beginning, anymore, as we have been told we can't do that, but because a DRG is collected, it makes no difference whether the DRG started on day 1 or day 2, the whole hospital stay gets bundled into a DRG, even if I don't write an order to back date the change.
Correct, a DRG is the same no matter how long the stay. When a patient is in OBV, you would bill an initial OBV code, correct? 99218-99220. When they are IP, you would bill an IP admission code, 99221-99223, correct? When you say you change your bill from OBV to IP, does this not affect reimbursement?
ReplyDeleteanon. You can do exactly as you said. I have never done it this way because I have never felt like doing the work of an entire new admission on day 2 when the switch is made, but you could do it and you should get paid. On day two when the obs to inpatient change is made, I bill an inpatient follow up code and change my original obs admission code to an inpatient admission code, since the whole thing will be bundled into an admission DRG by the hospital.
ReplyDelete