Admit and Discharge Same Day CPT® Codes Explained (99234-99236).

This medical billing and coding lecture describes how to use the admit and discharge same day CPT® codes 99234-99236.  CPT® stands for Current Procedural Terminology.  CPT®  codes are one component of the Healthcare Common Procedure Coding System (HCPCS).   Evaluation and management (E/M) codes, often referred to as the nonprocedural codes,  are the CPT® codes defined by the patient type, the setting of service and the level of service provided.  In this case CPT® 99234-99236 refer to observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date which requires certain key components that define the level of service.   This lecture will help the  physician and non-physician practitioner determine when using this group of admit and discharge same day codes is appropriate.

The same day admit and discharge codes are just several of many potential CPT® admission codes.   I refer the reader to my complete collection of CPT® code lectures that review the specific criteria of codes 99234, 99235 and 99236.  These lectures are on The Happy Hospitalist but organized through Pinterest in one easy to find pin board.  You don't have to be a Pinterest member to review any of my lectures.   They are all free for review.   I am a board certified internist with over ten years of clinical hospitalist experience.  What I write here is my interpretation of many resources I have studied over the years.   I highly recommend purchase of the American Medical Association's CPT® 2014 Standard Edition as the authority in CPT® billing and coding.  This can be purchased by clicking on the photo file below and to the right linking to Amazon. 

I start the discussion on same day admit and discharge codes with an analysis  of a question asked to me by a reader:
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 one 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 the patient comes in the day of and seen the day of. Let me explain.  The 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 doctor 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 8 hours 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.
I agree with you.  Here is the answer directly from a Medicare carrier.  Admit and discharge same day CPT® billing codes are to be used only when the physician provides an admission and discharge face-to-face encounter eight hours apart on the same calendar date, regardless of when the actual order for admission was written.  This definition was clearly defined in question 1 of this Q&A session by this Medicare carrier.   In their exact words, they state:
Medicare Part B adjudicates physician services based on the calendar date of the service. In the above situation, the physician would submit the combination hospital inpatient/discharge services (99234-99236).  In the Medicare Part B environment, the time of an "admission" to the hospital is not a physician payment issue. The physician service begins when he/she actually see the patient and performs the work for which Medicare may make payment. The "admission" time and date are necessary for the hospital billing, but not for the physician billing.
If the physician provides an initial admission face-to-face encounter on one calendar date and a second face-to-face  discharge encounter on another calendar date,  99234-99236 codes do not apply.   Do not use them, regardless of when the actual admission order was written.  Alternatively, as in the above scenario, if the  physician phoned in orders for inpatient or observation admission at 11 pm one calendar date and saw the patient two  times the following day and discharged them, admit and discharge same day codes 99234-99236 may still apply if the physician provided two separate  face-to-face encounters at least 8 hours apart and their documentation supported the use of 99234-99236 codes.  Clearly stated above,  the date of the order for hospital admission has no relevance on physician billing.  I think this is a big part of the confusion for physicians and their coding teams.  I know I have personally been confused about it in the past.  The patient's hospital stay may have crossed the magic midnight hour into a second calendar date, but the physician still provided the two face-to-face encounters on the same calendar date and Medicare Part B recognizes physician face-to-face encounters, not dates of hospital admission orders.

If the initial admission face-to-face encounter crosses the midnight hour and the discharge face-to-face encounter is provided on a different calendar date, the attending physician or non-physician attending practitioner should report an  inpatient  CPT® code from the 99221-99223 group as their initial inpatient hospital service on the date of their face-to-face encounter, regardless of when the date of the order for admission was written.  Of course, documentation should support the use of CPT® 99221-99223.    For observation admissions that cross the midnight hour, the attending physician or NPP  should report a CPT® code from the group 99218-99220 as their initial hospital service encounter on the date of their face-to-face encounter, regardless of the date the order for observation was written.  Again documentation should support the use of CPT® 99218-99220. These two groups of codes "most appropriately describe(s) the level of service provided" and that is the expectation of the Centers for Medicare & Medicaid Services (CMS).  Another document supports this concept as well.   In a Q&A resource from one Medicare carrier, they answered:  "If the documentation for the initial visit does not support one of the initial inpatient procedure codes, CMS has instructed contractors to not find fault with the physician billing a subsequent care procedure instead."

Only one E/M code can be submitted per day.  What if the physician only provided one face-to-face encounter for admission and discharge or they provided two face-to-face encounters on the same day but less than 8 hours apart? The physician in this scenario may have the option of choosing either the initial hospital encounter code or the discharge code, although there appears to be some conflicting information on the appropriate code in this case.   Which is the right code?  The right code is the code that "most appropriately describes the level of service provided". However, the right code may not be acceptable based on the definition of the code.   If you did an admission H&P and your documentation supports it, bill an H&P.  If you provided a discharge level of service and your documentation supports it, bill a discharge level of service (although I still don't recommend this because of conflicting information on billing discharge codes 99238 or 99239 or 99217 on the same date as the face-to-face initial encounter)..  If the patient stays until calendar day number three, use inpatient discharge codes 99238 and 99239 for inpatient discharges and 99217 for observation discharges on that third day.

ADMIT AND DISCHARGE FACE-TO-FACE ENCOUNTERS SAME DAY


What if the face-to-face admission and discharge encounters occur on the same calendar date.  Can the admit and discharge same day codes 99234-99236 always be used?  The answer is still no.  That's where it can get a bit tricky.  I have provided a detailed analysis below of situations that will commonly arise, especially in hospitalist medicine where day and night patient handoffs occur with frequency.   The hospital inpatient and observation admit and discharge same day codes (99234-99236) are CPT® admission codes that should be used if the attending physician or other NPP admits the patient to inpatient or observation and then discharges the patient with  two documented face-to-face encounters separated by 8 hours or more on the same calendar date, when documentation supports this group of codes.
  • What if the patient had admission and discharge orders on the same calendar date and spent at least 8 hours in inpatient or observation status  and the physician or NPP had two face-to-face encounters separated by eight hours or more and the documentation supported the admit and discharge same day CPT® codes 99234-99236?
    • Bill the appropriate level of service from CPT® 99234-99236.  
  • What if the patient had less than 8 hours of inpatient or observation hospital care on the same calendar date (two face-to-face encounters less than 8 hours apart) or only one face-to-face encounter for admission and discharge services?  Should the  provider bill the hospital inpatient initial care codes (99221-99223 or  99218-99220) or the discharge codes (99238-99239 or 99217)?  There is some discrepancy between what CMS says and what some Medicare carriers have instructed.  
    • CMS discussed this in section 30.6.9.1 of of change request 6740 of transmittal 1875 from December 14th, 2009.  They say bill the initial encounter codes. 
      • "When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from CPT code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, CPT® codes 99238 or 99239, shall not be reported for this scenario."
      • Extrapolation of this position would presume that observation discharge day service CPT®  99217 shall not be reported either.  
      • My opinion then is that if documentation does not support the initial inpatient care codes 99221-99223 or initial observation care codes 99218-99220,  then the inpatient subsequent care codes (99231-99233) or observation subsequent care codes (99224-99226) should be used instead.  These codes would satisfy the expectation of choosing codes that "most appropriately describe(s) the level of service provided". I discussed that above. 
    • However, one Medicare carrier (in question 2 of their Q&A) suggested the clinician could submit payment for a discharge code.  This contradicts the CMS transmittal linked above, therefore, I do not recommend it because according to the AMA definition of  the discharge codes 99238, 99239, and 99217, they  should be reserved for discharge services provided on a date different than the admission face-to-face encounter.CMS does not always follow the AMA definition and that may be where some of the confusion lies.  I discuss this in more detail below.  My recommendation is to provide an intensity of service that qualifies for the initial hospital admission codes in this situation. 
  • What if the physician or NPP provides two face-to-face encounters on a patient with admit and discharge orders on the same date separated by 8 hours or more, but the documentation did not support CPT® 99234-99236?
    • For inpatients, I again recommend choosing an inpatient subsequent care code (99231-99233).  For observation patients, I recommend choosing an observation subsequent care code (99224-99226) .  This gets back to the CMS statement that require physicians to "bill the available code that most appropriately describes the level of service provided".  There are no alternative codes from which to choose from   These are the codes that most appropriately describe the level of service provided. 
      • Can't the provider just bill the inpatient or observation discharge codes?  I would not.
        • Inpatient discharge codes 99238 and 99239 only apply to discharge services on days other than the date of admission, so this code cannot be billed as a stand alone code in this scenario because the date of discharge is the same as admission.  That's from the AMA definition.
        • Observation discharge code 99217 as well only applies to discharge services provided on a date other than the initial date of observation status, so this cannot be billed as a stand alone code either.  That's from the AMA definition.
      • Understand that CMS does not always follow the AMA definition.  This has happened with other CPT codes (such as prolonged service codes 99356 and 99357).  This may be where some of the confusion occurs. 
  • What if the provider did not provide two face-to-face encounters 8 hours apart?  All E/M codes require a face-to-face encounter.  That means inpatient initial care codes (99221-99223), observation initial care codes (99218-99220), inpatient hospital discharge codes (99238-99239) and observation discharge code 99217 all require face-to-face encounters.  CPT® codes 99234-99236 are the bundling of the admit and discharge codes under inpatient or observation status for patients with admit and discharge orders on the same calendar date.  This is why two separate face-to-face encounters are required for billing 99234-99236.  If two separate face-to-face encounters are not documented, then the provider should not use this bundled care code group.  They should choose the appropriate group of codes that best describes the level of service provided.  In most cases, that would be the initial hospital care codes for inpatient (99221-99223) or observation (99218-99220).
    • What if the provider phoned in hospital inpatient orders at 1 am and discharged the patient at noon, therefore providing one face-to-face discharge encounter  but not a face-to-face admission encounter.  What can they bill?
      • Since they did not provide two separate face-to-face encounters 8 hours apart, they can not use admit and discharge same day codes 99234-99236.  In addition, I do not believe they should bill inpatient discharge codes 99238-99239 or observation discharge code 99217 since these codes only apply to discharge services provided on a date different than the date of admission. The AMA says so.  However, CMS does not always follow the AMA definition.  As I said above, this is an area of confusion.  However, I try to avoid this confusion on admission by providing  an intensity of service the qualifies for initial encounter codes 99221-99223 or 99218-99220.   If the face-to-face encounter documentation does not support these initial hospital encounter codes, I would should instead choose the subsequent care codes for inpatient  (99231-99233) or observation (99224-99226) status patients. 
    • What if one hospitalist admits the patient at 1 am and another hospitalist discharges them at noon?  Since both hospitalists are part of the same group and specialty, they function as one physician.  Only one physician should report the bundled care code 99234-99236 if documentation from both physicians supports their use with two face-to-face encounters separated by 8 hours.  In my group, we have decided the admitting physician gets the credit for the bundled code.
    • Here are more scenarios when billing for shared services with non-physician practitioners.  
These are just a few common situations many doctors and NPP will experience in their day at the office. If you have other scenarios you'd like to discuss, please leave a comment below and I will try my best to address it.   My hope is that this lecture and the many others I have written help clinicians understand how to deal with these complicated scenarios that are common in our every day coding environment. You can see much more in my free lectures on  hospitalist coding as well as a great wealth of information in my hospitalist resource area.  




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1 Outbursts:

  1. Can u be biiled $1,110,000 for cpt 99217 4/1/2009 thru 7/1/2009. I'm auditing a bill like this. Seems illegal. It's a cost containment company.

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