Forum - Questions & Answers
Difference?
What is the difference between 99234 (observation) and 99243 (outpt). If the person is Observation, isnt that also outpatient?
I received a denial for 99222, with Observation auth and billed as outpatient.
The error is in the 99222 but I'm not exactly sure which to replace it with?
Can anyone clarify this for me please and thanks!
re: Difference?
99234 same day observation POS 22, 99243 outpatient consult POS 22 or 11, 99222 INpatient admission POS 21.
re: Difference?
The visit was marked as Observation in the hospital, POS is 22 (as pt never became inpt. Only 2 days as Obs)
So based on the fact that we were consulting and this was not an inpatient visit, I believe it should now be billed as 99243 and 22.
99243 can be billed as either 22 or 11 because both are considered an Outpt setting? Is that correct?
re: Difference?
When billing a consult code, you may want to double check that the carrier still accepts consult codes as for your subsequent question, if your payor accepts CPT® 99243 and the service was rendered in a hospital setting, the correct place of service code would be 22 place of service code 11 is primary used in an office setting but is further defined as Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. In the event the payor does not accept consult codes, you would bill the appropiate E/M code 99201-99215 based upon documentation.
re: Difference?
Great! Thank you for clarifying. I believe the carrier (Care Plus) will accept the 99243 code but I will call to double check.
I printed out a code mapping chart and your explaination just brought it all into perspective for me. Thank you so much!
re: Difference?
You would rightly receive a denial when billing CPT® 99222 with a POS code of 22 (outpatient) the correct POS code for CPT® 99222 is 21 (in patient). Please see the below definitions for Inpatient vs Outpatient (Observation). As for what you bill that is naturally contigent upon (1) that patient's status while at the facility and (2) what is documented.
Inpatient defined:
“An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight.” – CMS, IOMs, Publication 100-02, Chapter 1, Section 10
Outpatient observation services defined:
“The use of a bed for physician periodic monitoring and active monitoring by the hospital's nursing or other ancillary staff, for the patient care which are reasonable and necessary to evaluate an outpatient's condition or determine the need for an inpatient admission. ” - Novitas, Local Coverage Determination (LCD) L27548
re: Difference?
https://www.oxhp.com/secure/policy/observation_care_e_m_codes_311.html
Observation codes 99217-99226 can only be billed by admitting physician.
and
99243: Office consultation for a new or established patient, which requires these 3 key components:
detailed history
detailed exam
medical decision making of low complexity
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the presenting problem(s) and the patient's and/or family needs
Usually presenting problems are of moderate severity. Physicians typically spend 40 mins face-to-face with the patient and/or family (consults are not payable by Medicare)
