Chest Pain Clinic Observation CPT® Coding Reviewed.

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.  I have an 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:

What the ER bills has no bearing on what can bill. You are independent from their practice unless the ER physician is listed as the attending of record.  I assume they are not.    If you are the attending of record when you bring a patient into the hospital as an observation, you bill the CPT® 99218-99220 observation initial visit codes on the day you provide your face-to-face encounter.  You cannot bill for calling in admission orders.  If you phoned in orders at 11 pm June 1st, you cannot bill anything on June 1st.  If you came to the hospital and saw them at 6 am for the first time on June 2nd, you bill your observation admission code (99218-99220) on June 2nd.    You must be the attending.  Different codes and rules apply if you are not the attending physician.   Make sure to review the AMA's 2018 CPT manual as the definitive source in billing codes.

However, if the workup is completed and the patient is then discharged on June 2nd later in the day, the patient is considered to be discharged on the same calendar day that you saw them for your face-to-face admission.  If your initial face-to-face is at least eight hours earlier than your face-to-face discharge evaluation, you should instead instead use the global admit/discharge same day codes 99234-99236.  If you do not provide additional face-to-face time for discharge, I submit payment for only my initial code and do not submit the global same day 99234-99236 code.    

If you actually saw the patient for a face-to-face evaluation at 11 pm on June 1st and discharged the patient the next calendar day, you can submit a 99218-99220 initial evaluation code on on the first calendar day.  The only  code you can use for discharge the following day 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 on June 2nd
June 1st:  Bill CPT® 99218 or 99219 or 99220.  Pick which ever code your documentation supports in this face-to-face evaluation.
June 2nd:  Bill CPT® 99217. This is the only option. There are no other codes.
You are the attending on record and you provide your first face-to-face evaluation on June 1st and discharge the patient on June 1st. 
If your face-to-face evaluation and your discharge face-to-face evaluation are at least eight hours apart, submit a  bundled admit/discharge same day code CPT® 99234 or 99235 or 99236.  Pick whichever code your documentation supports.  If your face-to-face evaluations are not at least eight hours apart, you may not get paid for a bundled same day fee if the chart is audited.  Consider submitting payment for the admission code only and not the discharge code or consider waiting eight hours between your two visits!  If you do not provide a second face-to-face encounter on discharge, you should not bill for a bundled charge.  Bill only for your face-to-face encounter, which would be a 99218, 99219 or a 99220 if your documentation supports those codes. 
You are the attending on record and provide a face-to-face evaluation on June 1st and discharge them on June 3rd.
June 1st:  Bill CPT® 99128 or 99219 or 99220.  Pick whichever code your documentation supports.
June 2nd:  Bill the new 2011 observation follow up CPT® codes 99224 or 99225 or 99226.  Pick whichever 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?  If you found this entry looking for the CPT® code for chest pain, there is no such thing.  Diseases and symptoms are assigned an ICD code.  The ICD code for chest pain is 786.5.  CPT® codes, specifically E/M codes, are numbers based on the level of service provided.  See below.  
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.  I have provided an exhaustive review of these and many other coding scenarios for attending and consultant physicians seeing patients for their initial H&P encounter in observation or in-patient status.  I recommend you review that resource for additional coding education. 

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 following 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. 
If the patient is not a Medicare patient and you are asked to consult on an observation patient, then you should bill the outpatient consult codes (99241-99245) as your initial visit and use the outpatient established clinic codes (99211-99215) for additional hospital days. Now, the difficult part is knowing whether or not the patient has Medicare and which insurance companies still accept consult codes and which don't.  I can usually find out pretty easily if my patient has Medicare.  But I never know what the rules are for the private insurance companies.

I hope this helps.  This is a classic example of the evaluation and madness (E&M) we experience in our daily lives as physicians.  If you're looking for other great resources on hospitalist medicine, make sure to review my links to important hospitalist resources.  


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