Observation CPT Billing Codes 99234, 99235, 99236, 99217, 99220 Explained

From the question gallery comes another question about billing observation status.

Dear Happy,

This is in regards to 99234-99236. There are 3 certified coders including myself who work in the physician building and then we have 1 certified coder who works in auditing.

Now: Supposedly the auditor is telling us per our Medicare Carrier that the only way the physicians can bill 99234-99236 is when then patient comes in the day of and seen the day of. Let me explain. Patient comes into the hospital 3/1/09 late night, but the doctor doesn't see the patient until 3/2/09 and then discharges them 3/2/09. The auditor said the only thing the doctors can bill is 99217 because the Dr did NOT get into the hospital on 3/1/09.

NOW...

I disagree.... I feel the date of observation starts when the Dr comes in to see the patient on 3/2/09. Therefor as long as the patient was in there longer than 8hours it is appropriate to bill the 99234-99236.

Now comes the sad part.... we can not find anything in the AMA that agrees with us...so the hospital is listening to the Auditor and making all the doctors bill discharge only. Until we can present proof from the AMA or different from our medicare carrier we have to start billing all these OPO as 99217.

Do you have anything in writing from the AMA regarding the codes 99234-99236?

From what I can tell from your website you agree with what we have to say with the 99234-99236.

I need your help!!!!!! Please email me if I have confused you... I am confused myself.

Dear Coding Specialist. I'm sorry to say, that you are wrong, and your auditor is right (but only part right). The ONLY time. Let me repeat that, the ONLY time physicians can bill using the observation/discharge codes 99234-99236 is when the patient is "admitted" and discharged in the same calendar day. This is not based on when the physician sees the patient, but rather when the hospital lists their "admitting" and discharge dates.

In your example above, because the patient was "admitted" on 3/1/09 and discharged on 3/2/09 they have crossed the elusive midnight hour and therefor they are considered to have been present for two calendar days. The only thing that matters is that the hospital has the patient listed as being admitted on 3/1/09 and discharged on 3/2/09. The fact that the physician did not see the patient until 3/2/09 changes nothing.

I deal with this scenario a lot when I'm admitting patients from the ED late at night. If I am in the ED and I first start my evaluation at 11:59 pm on 3/1/09 and decide after a 45 minute evaluation to admit the patient, it may be 00:45 am on 3/2/09 by the time I tell the ED charge nurse that I'm going to admit the patient observation status. But I tell them to make damn sure that the admit date is 3/1/09 because that's when I first started my evaluation. If the hospital lists 3/2/09 as the admit date and I submit a bill on 3/1/09, no matter what the charge is, my charge will get denied because the patient was not in the hospital on 3/1/09.

You can see much more here in my coding lectures or earn CME at E&M University

It makes no difference when the physician sees the patient. What matters is what calendar day the hospital lists as admission.

Therefor, a simple way to remember it is: If the hospital lists the admit date as a different calendar date as the discharge date, the physician CANNOT use the admit/discharge same day codes 99234-99236, even if the physician themselves saw and discharged the patient on the same date. If the patients admission and discharge calendar days are different then the physician must use the 99218-99220 for admission and 99217 for discharge.

The only thing I would disagree with from the auditor is that if a patient was admitted on 3/1/09 and discharged on 3/2/09, but the only date the physician saw the patient was 3/2/09, if the physician does an H&P, I would bill the H&P because it generally pays more than the discharge. If the physician does an H&P on 3/2/09, they should get paid for an H&P for 3/2/09, even though the admission date is 3/1/09. You get paid for the work you do. The physician can't bill both a 99218-99220 and a 99217 because Medicare will only accept one E&M code on a calendar day of service. So I say pick the one that pays more, which is more likely the 99218-99220, not the 99217.

I hope that helps. BTW. I'm not a professional coder, but this is my understanding of the rules as I interpret them.

As a side note, this only strengthens my assertion that E&M coding does nothing but add layers of complexity to the delivery of health care while adding nothing but inefficiency and cost to the bottom. We have professional coders who disagree. Happy's Hospital group does an in house audit several times a year. I am finding that I have to correct my own billing company's auditors when they claim I over or under bill. The Medicare auditors themselves have their own opinions and you'll get 10 different opinions from 10 different Medicare auditors. E&M coding is that loud sucking sound of money going right into a black hole. It is irrational, expensive and unnecessary to do my job. But it's here because some genius thought it was a brilliant idea. They have no idea how it bogs downs the delivery of health care into a giant inefficient and expensive failed grand experiement.

You can see much more here in my coding lectures or earn CME at E&M University