Hospital Observation Services 99217-99220 and 99234-99236
Placement in observation status requires an order from a provider with admitting privileges. Patients are in observation to determine whether the patient should be admitted to the hospital, transferred to another facility, or sent home.
When there is a three-day observation period, the middle day is coded with an established outpatient visit code, 99211-99215 based on the documentation.
The following services are not covered as outpatient observation services:
• Observation services that exceed 24 hours unless an exception is deemed necessary following a medical necessity review.
• Services that are not reasonable or necessary for the diagnosis or treatment of the patient but are provided for the convenience of the patient, his or her family, or a physician/provider (e.g., following an uncomplicated treatment or procedure; physician/provider busy when patient is physically ready for discharge; patient awaiting placement in a long-term care facility).
• Inpatient services.
• Services associated with ambulatory procedure visits.
• Routine preparation services furnished prior to the testing and recovery afterwards (e.g., patients undergoing diagnostic testing in a hospital outpatient department).
• Observation concurrent with treatments such as chemotherapy.
• Services for postoperative monitoring.
• Any substitution of an outpatient observation service for a medically appropriate inpatient admission.
• Services that were ordered as inpatient services by the admitting physician/provider but reported as outpatient observation services by the hospital.
• Standing orders for observation following outpatient services.
• Discharges to outpatient observation status after an inpatient hospital admission.
When a patient is admitted from observation status, the ADM record for the observation care should be closed out with a disposition type of “admitted.”
When a patient is referred from observation to an ambulatory procedure unit (APU) or another MTF, the ADM record for the observation care is closed out with disposition type of “immediate referral.”
E&M codes will be used to document the length and acuity of observation care services in ADM. Observation E&M codes relate to the number of calendar days (dates) the patient spends in observation status and the acuity of the stay.
Observation new cpt code - 99218, 99219, 99220, 99224, 99225, 99217
Initial Observation care:
99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of low severity.
99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of moderate severity.
99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity.
Subsequent Observation care: New codes effective from Jan 1, 2011
99224 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.
99225 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination;
Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit
99226 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination;
Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.
Observation discharge:
99217 Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge from "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])
Hospital Observation care CPT code 99234 - 99236
Documentation Requirements for Billing Hospital Observation care CPT code 99234 - 99236 Observation or Inpatient Care Services (Including Admission and Discharge Services (Codes 99234–99236))
The physician should satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. In addition to meeting the documentation requirements for history, examination and medical decision-making, documentation in the medical record shall include:
* Documentation noting the stay for observation care or inpatient hospital care involves eight hours, but less than 24 hours.
* Documentation identifying the billing physician was present and personally performed the services.
* Documentation identifying the order for observation services, progress notes and discharge notes were written by the billing physician.
In the rare circumstance when a patient receives observation services for more than two calendar dates, the physician should bill a visit furnished before the discharge date using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.
Admission to Inpatient Status Following Observation Care
* If the same physician who ordered hospital outpatient observation services also admits the patient to inpatient status before the end of the date on which the patient began receiving hospital outpatient observation services, Medicare should pay only an initial hospital visit for the E/M services provided on that date.
* Medicare payment for the initial hospital visit includes all services provided to the patient on the date of admission by that physician, regardless of the site of service.
* The physician may not bill an initial observation care code for services on the date he admits the patient to inpatient status.
* If the patient is admitted to inpatient status from hospital outpatient observation care subsequent to the date of initiation of observation services, the physician must bill an initial hospital visit for the services provided on that date.
The physician may not bill the hospital observation discharge management code (99217) or an outpatient/office visit for the care provided while the patient received hospital outpatient observation services on the date of admission to inpatient status.
Hospital Observation Services During Global Surgical Period
The global surgical fee includes payment for hospital observation (codes 99217, 99218, 99219, 99220, 99234, 99235 and 99236) services unless the criteria for use of modifiers 24, 25 or 57 are met. These services are paid in addition to the global surgical fee only if both of the following requirements are met:
* The hospital observation service meets the criteria needed to justify billing it with modifiers 24, 25 or 57 (decision for major surgery).
* The hospital observation service furnished by the surgeon meets all the criteria for the hospital observation code billed.
Initial Observation Care Codes 99218–99220
Who May Bill Initial Observation Care
Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.
Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring to make a decision concerning their admission or discharge.
In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in fewer than 48 hours, usually in fewer than 24 hours.
* Payment may only be made to the physician who ordered hospital outpatient observation services and was responsible for the patient during his observation care.
* A physician who does not have inpatient admitting privileges but who is authorized to furnish hospital outpatient observation services may bill these codes.
* There must be a medical observation record for the patient that contains dated and timed physician’s orders regarding the observation services the patient is to receive, nursing notes and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.
* Payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient’s observation services began. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.
Example:
If an internist orders observation services and asks another physician to additionally evaluate the patient, only the internist may bill the initial observation care code. The other physician who evaluates the patient must bill the new or established office or other outpatient visit codes as appropriate.
Physician Billing for Observation Care Following Initiation of Observation Services
When a patient receives observation care for less than eight hours on the same calendar date, the initial observation care from CPT code range 99218–99220should be reported by the physician. The observation care discharge service, CPT code 99217, should not be reported for this scenario.
When a patient is admitted for observation care and then is discharged on a different calendar date, the physician shall report initial observation care from CPT code range 99218–99220 and CPT observation care discharge CPT code 99217.
When a patient receives observation care for a minimum of eight hours but less than 24 hours and is discharged on the same calendar date, observation or inpatient care services (including admission and discharge services) from CPT code range 99234–99236 should be reported. The observation discharge, CPT code 99217, cannot also be reported for this scenario.
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