A cardiologist recently asked me a question on how to bill his chest pain clinic observation patients. While this post is in response to the chest pain clinic observation patients, it can be applied to any observation patient.
Good morning. What the ER bills has no bearing on what can bill. You are independent from their practice. If you are the attending of record when you bring a patient into the hospital as an observation, you bill either the 99218, 99219 or 99220 (low, medium, high) observation admit codes. You must be the attending. Different codes and rules apply if you are not. Again. These rules only apply if you are the attending/admitting physician.
You are the attending on record and you bring someone in observation June 1st and discharge them June 1st
You are the attending on record and bring someone in observation on June 1st and discharge them June 3rd.
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I have a E/M question that I haven't been able to figure out. I'm a cardiologist and our hospital recently opened up an observation unit so we're running into all the observation issues more frequently. If a regular patient of my practice goes to the ER, is seen by the ED doc, who requests I see him to decide on admit/discharge and I decide to put him in observation and do the orders/H&P, can I bill for an observation admission or do I still bill for an outpatient follow up since the ER doc has already billed an E/M code for ER care? If I discharge the patient the next day can I bill for that? Thanks in advance!
Here is my response:
Good morning. What the ER bills has no bearing on what can bill. You are independent from their practice. If you are the attending of record when you bring a patient into the hospital as an observation, you bill either the 99218, 99219 or 99220 (low, medium, high) observation admit codes. You must be the attending. Different codes and rules apply if you are not. Again. These rules only apply if you are the attending/admitting physician.
If the patient is discharged on the same calendar day you must cancel using the 99218, 99219 or 99220 codes and instead use just the bundled admit/discharge same calendar day code 99234, 99235, or 99236 (low, medium, or high) admit/discharge same day code.
If the patient is admitted observation one calendar day and discharged the next calendar day, you bill the 99218, 99219 or 99220 on the first calendar day and the only code you can use for the discharge is the observation discharge code 99217.
So here are the three scenarios:
You are the attending on record and bring someone in observation on June 1st and discharge them June 2nd
You are the attending on record and bring someone in observation on June 1st and discharge them June 2nd
June 1st: Bill CPT® 99218 or 99219 or 99220 (low, medium and high codes). Pick which ever code your documentation supports.
June 2nd: Bill CPT® 99217. This is the only option. There are no other codes.
You are the attending on record and you bring someone in observation June 1st and discharge them June 1st
You must submit a bundled admit/discharge same day code 99234 or 99235 or 99236 (low, medium or high). Pick which ever code your documentation supports.
You are the attending on record and bring someone in observation on June 1st and discharge them June 3rd.
June 1st: Bill CPT® 99128 or 99219 or 99220 (low, medium or high codes). Pick which ever code your documentation supports.
June 2nd: Bill the new 2011 observation follow up CPT® codes 99224 or 99225 or 99226 (low, medium or high codes). Pick which ever code your documentation supports.
June 3rd: Bill CPT® 99217 observation discharge. This is the only option. There are no other codes.
Whether you bill the low, medium or high codes is dependent on what your documentation supports.
That's how you bill your E&M CPT® codes for an observation stay in the chest pain clinic, if you are the attending on record. But, what if you aren't the attending/admitting physician? How are you supposed to bill your daily visits on a chest pain clinic observation admission, or any observation admission for that matter? Read on.
If you are the consultant on an observation patient admitted by say, the hospitalist, none of the above applies because you aren't the attending physician. These CPT® codes (99218, 99219, 99220, 99217, 99234, 99235, 99236, 99224, 99225, 99226) are only to be used by the attending physician.
If you are a cardiologist or oncologist or nephrologist or even a hospitalist asked to consult on an observation patient that was admitted by another physician that patient is considered outpatient so you have to use the outpatient consult codes. But here is where it gets complicated.
If the patient is a Medicare patient, outpatient consult codes no longer exist. So, if you are asked to consult on an observation patient admitted by another service and that patient is a Medicare patient, you are to use the follwing rules
For our group, I still bill consult codes when in doubt about whether they will get paid when I am asked to consult on an inpatient or whether I am asked to consult on an observation patient and then I let our billing company change the code to the correct code based on what the insurance allows.
I hope this helps. This is a classic example of the E&M "Evaluation and Madness" we have to go through in order to get paid for the work provided. And if we don't get it right, every time, thousands of times a year, we don't get paid and even worse, Obama will accuse us of Medicare fraud.
If you are a cardiologist or oncologist or nephrologist or even a hospitalist asked to consult on an observation patient that was admitted by another physician that patient is considered outpatient so you have to use the outpatient consult codes. But here is where it gets complicated.
If the patient is a Medicare patient, outpatient consult codes no longer exist. So, if you are asked to consult on an observation patient admitted by another service and that patient is a Medicare patient, you are to use the follwing rules
- If the patient has not been seen by you or any of your partners (of similar specialty) in the last three years, and you have been asked to consult on an observation patient, on your initial evaluation, bill the new patient outpatient clinic codes (99201-99205). Your follow up visits should be billed as the established patient outpatient codes (99211-99215). On the day the patient is released from their observation stay, continue to bill the established outpatient codes (99211-99215). Only the attending/admitting physician can bill the observation discharge code 99217.
- If the patient has been seen by you or any of your partners (of similar specialty) in the last three years and you have been asked to consult on an observation patient, on your initial evaluation, you can only bill the established outpatient clinic codes (99211-99215). Continue to bill these codes for all your daily evaluations.
For our group, I still bill consult codes when in doubt about whether they will get paid when I am asked to consult on an inpatient or whether I am asked to consult on an observation patient and then I let our billing company change the code to the correct code based on what the insurance allows.
I hope this helps. This is a classic example of the E&M "Evaluation and Madness" we have to go through in order to get paid for the work provided. And if we don't get it right, every time, thousands of times a year, we don't get paid and even worse, Obama will accuse us of Medicare fraud.
Hope that helps!
LINK TO E/M POCKET REFERENCE CARD POST
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