Forum - Questions & Answers

Dec 17th, 2009 - signaturedoc

Observation code

Patient in ED at 6 pm with chest pain, placed on Observation status at 9pm, not seen by primary MD, only ED Doc. Family MD sees the patient at 10 am and sends them home. Is this a 99234 (admit and discharge same day) even though the patient was in hospital two calendar days?

Dec 21st, 2009 -

hey Editor

I post enough responses to at least get your opinion on this one. Or admit it's not clear and I'll stick with 99234.

Dec 22nd, 2009 - Codapedia Editor 1,399 

Observation

I leave the hard questions to you, and I answer the easy ones. (I apologize, I've been traveling and not following as closely as I should have.)

You can't bill 99234--99236 for two reasons: different calendar date, and you didn't see the patient in the ED.

In order to bill for a service, you have to see the patient. You can't bill for anything that happened in the ED if you didn't come in to the hospital. All you can bill for is the service you personally performed on the date you saw the patient.

I think all you can bill is the discharge on the day you came in. 99217

If you had come in, 99218--99220 on day one, 99217 on day two.

HERE IS YOUR ORIGINAL QUESTION: DOES ANYONE ELSE HAVE ANOTHER OPINION?
Patient in ED at 6 pm with chest pain, placed on Observation status at 9pm, not seen by primary MD, only ED Doc. Family MD sees the patient at 10 am and sends them home. Is this a 99234 (admit and discharge same day) even though the patient was in hospital two calendar days?

Dec 22nd, 2009 -

but...

when I saw the patient I performed a full initial evaluation and then reviewed tests and determined the patient could be sent home. I cannot discharge a patient from Observation that I did not admit to Observation....

Dec 22nd, 2009 - dsteed   141 

Observation

Actually, there are 2 separate issues. The hospital's observation time begins with the clock time as noted by the nurse that the patient is officially in observation status per physician order. For Medicare, the allowance is 48 hours, or until all interventions ordered prior to the observation limit have been completed. Many managed care payers only allow 23 hours in observation. The hospital's observation time spans 2 calendar days.

The physician only has 1 day to consider if the patient was not seen until after midnight. What you will end up with is probably conflicting codes submitted by the hospital & physician, with the hospital submitting 99218-99220 & 99217, with the MD submitting 99234-99236. Depending upon the payer, they may request records to determine exactly what occurred.

Dec 22nd, 2009 -

This is a dilemma

this happens all the time; docs round in the morning, get a new patient in the afternoon or evening placed on Observation and give orders over the phone, do not go see them until the next morning when they are better (ruled out for MI, rehydrated, asthma better) and do the "H&P" and discharge them.
In 17 years I have never been asked for records and I used 99234-6 for the one visit.
Perhaps a CMS representative is reading this and can get us a formal answer...we are big enough and influential enough to get CMS' attention.

Dec 22nd, 2009 - Codapedia Editor 1,399 

Observation dilemma

I see the problem: you did both pieces of the admit and discharge, the admit was done over the phone. I can't find anything in the manual to support being able to bill the admission when you didn't go in.

And, if you did, you should bill the admit codes on Day 1 (99218--99220) and the discharge the next day, since 99234-99236 require the same calendar date.

Jan 15th, 2010 -

Update on this question

I talked to WPS- our CMS MAC and they say the doctor should bill 99234-6- admit and discharge from observation on same calendar day since the physician service occurred on the same day irrespective of the hospital day of admit and discharge.

Jan 15th, 2010 -

observation

signature doc, you are my hero.



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