Re: OBSERVATION VISITS
From: Anna Meenan, MD (annam@uic.edu)
Thu Aug 14 11:57:17 2003
Garry,
It is a little confusing. So confusing, in fact, that I gave you the
wrong code for this case. If the hospital insists that this must be an
obs. visit, then the code for obs admit/discharge same day is 99234,
which is actually 2.56 RVU's. I think that is overkill, but if the
hospital is going to insist, I would bill for it and then bring the
denials to the hospital administration and raise h*ll.
The observation codes are explained pretty well on the ACP website. See
below: The website is
http://www.acponline.org/journals/news/apr00/cptcodes.htm (and I still
don't know how to make links)
--
Anna Meenan, MD
Q: When do I use the hospital observation services codes (CPT
99217-99220) vs. the observation or inpatient care services, including
admission and discharge services codes (CPT 99234-99236)? What about the
hospital discharge services codes, CPT 99238-99239?
A: An observation care discharge service (CPT 99217) is used for
patients who were in "observation status" and discharged from the
hospital on a day other than the day they were admitted for observation.
Report an initial observation care code (CPT 99218-99220) for encounters
with patients while they are in observation status.
Use an observation or inpatient care services (including admission and
discharge services) code (CPT 99234-99236) for patients who are admitted
to and discharged from observation status or inpatient status on the
same day.
Report a hospital discharge services code (CPT 99238-99239) for patients
who are discharged from inpatient status on a day other than the day
they are admitted.
The following scenarios help illustrate how you should use these codes:
* Scenario one. You decide to keep a patient for observation on a
Tuesday. You initiate the observation, supervise the observation care
plan and periodically assess the patient. On the following day, you
decide the patient is well enough to go home. You discuss the patient's
stay, give instructions for ongoing care and prepare discharge records.
The patient is released from the hospital altogether. You should report
an initial observation care code, CPT 99218-99220 for Tuesday, and an
observation care discharge service, CPT 99217, for Wednesday.
* Scenario two. You keep a patient in the hospital for observation on a
Tuesday. You perform the same services relating to the initiation of
observation status as described in scenario one. Later that day, you
determine that the patient is well enough to be released and you furnish
the same discharge services described in scenario one. You should
report an observation or inpatient care service (including admission and
discharge services), CPT 99234-99236, for that day.
* Scenario three. You admit a patient as an inpatient on a Tuesday. You
take the patient's history. You provide an examination of the patient
that involves some level of medical decision-making (for example, you
provide an initial hospital service, CPT 99221-99223). You check on the
patient later in the day and decide he or she is well enough to be
discharged. You do a final examination of the patient, give
instructions for continuing care, prepare discharge records and write
the patient a prescription (for example, you provide a hospital
discharge service). The patient is discharged from inpatient status on
the same date as the admission. You should report an observation or
inpatient care service, CPT 99234-99236, for that day.
* Scenario four. You admit a patient as an inpatient on a Tuesday. You
provide an initial hospital service as described in scenario three.
During your rounds on the following day, you determine the patient has
improved enough to be released. You perform the hospital discharge
service as described in scenario three. The patient is discharged from
inpatient status a day after the admission. You should report an
initial inpatient service, CPT 99221-99223, for Tuesday, and a hospital
discharge service, CPT 99238-99239, for Wednesday.
Q: How much do Medicare payments for these services vary?
A: Medicare pays a comparable amount for each scenario described above.
The reimbursement amounts are as follows (actual reimbursement will vary
slightly by geographic region):
* Scenario one. Total reimbursement for CPT 99219 (initial observation
care service) and CPT 99217 (observation care discharge service) comes
to $182.32.
* Scenarios two and three. Total reimbursement for CPT 99235
(observation or inpatient care service) totals $171.70.
* Scenario four. Total reimbursement for CPT 99222 (initial inpatient
service) and CPT 99238 (hospital discharge service) is $182.32.
At Wed, 13 Aug 2003, Garry E. Siegel, M.D. wrote:
>
>Anna:
>
>I've not been able to understand the subtle differences in using
>observation codes--there are a couple of different categories. Can you
>shed some light, either on the forum, or by private email?
>
>I would have coded this as an outpatient E/M, at the level supported by
>the history/exam, or more likely, the time element--just as you
>suggested.
>
>Also, welcome new physician, and I second what Anna has said: please
>take a moment and introduce yourself.
>
>Garry
>
>At Wed, 13 Aug 2003, Anna Meenan, MD wrote:
>>
>>OK, here is how I would look at this, if it occurred at my hospital,
>>which it doesn't. If coded as an outpt. visit, this would code out to
>>be a 99213, or 0.67 RVU's (you can't code it based on time spent at
>>bedside if it's an outpt. visit, since you didn't spend >50% of the
>>visit doing counseling and coordination of care). If coded as an
>>observation visit, it would code out as a 99218, or 1.28 RVU's. Since
>>most OB pt's are relatively healthy and you often know quite a bit of
>>their history already or have a prenatal on file with all of it already
>>recorded, doing a quick H&P shouldn't add much more than 5 minutes to
>>the visit, ten max. Since you've already hauled your butt up to the
>>hospital, why not get paid better for a few more minutes of work? That's
>>how I would look at it.
>>
>>BTW, I haven't seen your name on the forum before. Introduce yourself
>>if you're new, and welcome to the List.
>>
>>--
>> Anna Meenan, MD, FAAFP
>>
>>At Wed, 13 Aug 2003, Wilma Harrell wrote:
>>>
>>>ALL patients who present to L&D on the weekends and weekday nights are
>>>admitted as "observation". I don't know why, but this is what occurs.
>>>It does not matter how trivial the complaint is, or how quickly it is
>>>resolved...ALL are admitted to "observation" as a matter of protocol.
>>>Who made the protocol is another question.
>>>A 16 yo who is full term presents for vaginal itching. An NST is
>>>automatically performed (protocol). I arrive at the psatient's bedside,
>>>perform a speculum exam, confirm a yeast infection, and interpret the
>>>NST. I spend 20 minutes at the patient's bedside.
>>>IF THE PATIENT IS TRULY "OBSERVATION" THEN I CANNOT BE PAID UNLESS I
>>>DICTATE AN ENTIRE H&P FOR A RIDICULOUS YEAST INFECTION. IF THIS PATIENT
>>>IS CALLED "OBSERVATION" BUT IS ACTUALLY AN "OUTPATIENT" I CAN DICTATE A
>>>SIMPLE NOTE INCLUDING THE TIME SPENT AT THE BEDSIDE AND CHARGE AN
>>>"OUTPATIENT" CODE.
>>>These ridiculous situations are endless. The list goes on and
>>>on...yeast infections, heart burn, nausea, headache. None of these
>>>20-30 minute visits necessitate an H&P. Why should I have to jump
>>>through these hoops?
>>>Is it incorrect to label each patient (no matter what) as observation?
>>>Is it incorrect to call it "observation" when it's really just an
>>>"outpatient" type visit?
>>>For the purposes of medicaid, can these be billed with "outpatient"
>>>codes inspite of the "observation" misnomer?
>>
>--
>Garry E. Siegel, M.D.
>Private Practice
>Roswell, GA
>
