Re: OBSERVATION VISITS
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Thu Aug 14 20:51:03 2003
Thanks for the link; I'll review it.
Garry
At Thu, 14 Aug 2003, Anna Meenan, MD wrote:
>
>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
>>
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
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