# Outpatient Observation 99234-99236



## vjst222

Ok all my E/M friends, I need your help. I am having troubles understanding the 99234-99236. Here is my dilema.
 Now keep in mind I am billing for the physician, not the hospital.

 I have a patient that comes into the ER at 11:59PM on Monday 6th. The ER goes ahead and admits him to OPO on Monday the 6th. However, my Dr does not come in until Tuesday morning on the 7th to do his H/P. Well later that evening on the 7th, the Dr has decided to go ahead and discharge the patient. 
 Now here is the problem.I have been told 2 different ways on how I should bill this.

1st way: The dr can bill 99234-99236 since he didn't actually see and discharge the patient until Tuesday 7th. 

 or

2nd way: Since the patient came into the ER the night before the only thing the Dr can bill is the 99218-99220 or 99217 because it has already crossed over the midnight mark. Therefor the Dr can only bill for Tuesday 7th 99218-99220 or 99217.

 Now I have searched and searched everywhere for proof on what to do, and I Have had 4-5 different opinions both different. Does anyone know what the AMA says about this? We have tried contacting them but never receive an answer. I need some input....real actual input...

 Thanks


----------



## FTessaBartels

*The date the service is provided*

You code the service on the date the service was provided.

In your scenario the physician saw the patient "initially" on the 7th; the physician happened to also discharge patient this same date of service.

Because these two events cannot be billed separately on one date of service, you would appropriately use the 99234-36 (admit/discharge on same date of service) code to describe the services provided by the physician on this one date of service.

Hope that helps.

F Tessa Bartels, CPC, CEMC


----------



## vjst222

I will be honest with you, that is what I think along with about 2 other coders, however the hospital is making  us bill the discharge only. Their arguement is... the patient  came in the night before, therefor since the dr didn't come in that night to see them they can't bill the 24 hour admit/discharge. The hospital is making us bill these with 99217 only. I think this is crazy, but I can't get proof from AMA to defend my case. All I seem to be getting are a bunch of opinions. 
 So I can't code it properly because of the hospital....


----------



## FTessaBartels

*Why does the hospital have a say?*

I don't understand ... why does the hospital have any say in how the physician's services are coded?

F Tessa Bartels, CPC, CEMC


----------



## vjst222

Because the Drs are all employed by the hospital and we have a auditor whom thinks that is how it should be done. Instead of the hospital listening to 3 certified coders, one being here longer that 25 years... they listen to an auditor who has been a coder no longer than 5 years.
 Honestly, I don't know what is going on, we just have to "follow" the rules and until I can get written proof from the AMA or our local medicare carrier we will continue doing the way the hospital wants  us to. Some of the Dr's are even disagreeing, but it doesn't matter....because the hospital runs the show.


----------



## vjst222

Anyone else out there have anything to help me?


----------



## LLovett

*Per CMS*

http://www.cms.hhs.gov/transmittals/downloads/R1466CP.pdf


"B. Policy: When a patient is admitted to observation status for less than 8 hours on the same calendar date, the physician shall report Initial Observation Care using a code from CPT code range 99218 – 99220. The Observation Care Discharge Service, CPT code 99217, shall not be reported for this scenario. When a patient is admitted for observation care and discharged on a different calendar date, the physician shall report an Initial Observation Care using a code from CPT code range 99218 – 99220 and CPT code 99217 for the Observation Care Discharge Service. *When a patient is admitted to observation status for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, the physician shall report the Observation or Inpatient Care Services (Including Admission and Discharge Services) using a code from CPT code range 99234 – 99236, and no additional discharge service. *Physician documentation shall meet the evaluation and management (E/M) documentation requirements for history, examination and medical decision making. In addition, the physician shall document he/she was physically present and that he/she personally performed the observation care services. The physician shall personally document the admission and discharge notes and include the number of hours the patient remained in observation care status. In rare circumstances when a patient is held in observation status for more than 2 calendar days, the physician shall bill a visit from CPT code range 99211 – 99215 (Office or Other Outpatient Visit) furnished before the discharge date."

The physician is doing all their work on the same calendar date so I would think this would apply.
Hope this helps your case

Laura, CPC


----------



## vjst222

Thanks for the info Laura, I already had this info. BUT here is the loophole. The hospital says the patient came into the hospital the night before, therefor since the patient was not seen by their doctor in the hospital the night before the Dr can only bill the 99217 ( that is the hospital definition. ) I agree with everyone, I think it is based on what the Dr does not when the patient walks in the door.

 Let me ask everyone ...now does this sound logical to you? *note this is what the hospital thinks*

 A patient walks in April 22 at 11:59pm, therefor since they walked in 1 minute before the day changes over it automatically puts them in over the next day or for 2 days. Although there is no way for the Dr to be there that very minute, therefor the only thing our doctor can bill for a patient who is in and out on April 23rd is 99217. That isn't even logical to me.

 Shows how powerless we are sometimes..


----------



## coliver

*99234-99236*

Ok ladies, I also have this problem but I am looking at it differently. I want to know if the code requires two face to face visits. The description doesn't say this is required. The provider goes in on the seventh and does the work for the initial and does the work for the discharge.....all in one face to face visit, can you then bill the 99234-99236. Do you know if your provider is having two face to face visits or just one?


----------



## cheermom68

*observation*

Luna,
Ask the auditor for documentation to support their position.


----------



## Karolina

In my opinion, you are right Luna. And keep in mind that the hospital admit date does NOT have to be identical to the physician admit date. Of course, observation is an outpatient service, but I think this is what the hospital is getting hung up about. Everyone here - including myself - seems in agreement that the 99234-36 codes apply. I do like cheermom's comment! Have the auditor provide the evidence that s/he's right.
I assume you already contacted your carrier with this scenario? They might be able to provide a good resource.


----------



## FTessaBartels

*Response to COLIVER*

Yes, all the service can be performed in ONE face-to-face visit. You do not need to have two separate f-t-f visits on the same DOS to code 99234-99236.

F Tessa Bartels, CPC, CEMC


----------



## mb12345

Hi Everyone!

We are having the same issue.  My scenario is the resident goes in on the 6th say 11:00 pm, the attending does not see the patient until the 7th and discharges the patient later the same day.  Some say this is observation admit and discharge and other say no b/c it is different calendar dates.  

Clarification on "admit" might be helpful.  Does Medicare refer to the calendar date as the actual date the patient entered the hospital or does it refer to the date the physician saw the patient.  In our circumstance we allow the attending 24 hrs to utilize the residents documentation but some of the billing staff are concerned that the date of admit won't match the hospitals and that the claim will be denied.  Any thoughts on the correct code?  I had originally said admit and discharge same day?  We are in Virginia.

Thanks for your help!
Mary Beth


----------



## SCanterbury

When the admitting physician (attending, not a resident) sees the patient for the first time the morning after the patient was admitted and discharges the patient, you should NOT bill 99234-99236. It is true that the attending performed his/her initial visit on Day 2, but the 99234-99236 series is NOT an "_Initial Visit _and Discharge Same Day" series. It is only to be used when the patient was actually admitted and discharged the same day.

For the situation you describe, CPT instructs (in the 6/02 CPT Assistant) that you bill a discharge only:

"_Question 
A patient is admitted for observation before midnight. The physician does not see the patient until the next day, which is also the date of discharge. The physician performs the discharge examination, discusses the patient’s stay, and gives instructions for care following discharge. Should I report codes 99234-99236 for this service? 

AMA Comment 
From a CPT coding perspective, codes 99234-99236, Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, may be reported only when the patient is actually admitted and discharged on the same date of service. The physician should not report these codes when the patient is admitted one day and discharged the next day. In this case, the patient is in the hospital for two dates of service, so the physician should report the discharge services performed on the second day of admission, which is also the date of discharge_."

Realize that this CPT instruction assumes that the attending physician performed a "discharge examination" when they first saw the patient, implying that the first service by the attending occurred long after the admission and had the primary purpose of clearing the patient for discharge. In cases where this assumption is not valid--say the attending came in at 1:00 am a few hours after the patient was admitted and the attending performs a pretty comprehensive initial evaluation--then it may be more accurate (and fair from a reimbursement standpoint) to bill an Initial Hospital Care code only instead of a Discharge code only. Base your decision on the nature of the admitting's first service. But to code correctly, it has to be one of those two only, as CPT has made it clear that it is not appropriate to use the 99234-99236 series if the patient was not actually admitted and discharged the same day.

Seth Canterbury, CPC, ACS-EM
Education Specialist
University of Florida Jacksonville Physicians, Inc.
Clinical Data Quality-Education Department
653 West Eight Street
Tower I, Suite 606
Jacksonville, FL 32209
(904) 244-9643


----------



## sherryjean27

Does everyone else still believe that you can bill 99234-6 for this. Since the dr's admit and d/c is on the same date, why would this not be allowed to be chosen.

_"From a CPT coding perspective, codes 99234-99236, Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, may be reported only when the patient is actually admitted and discharged on the same date of service." _

Even using this guideline, *for the physician*, the pt is being admitted and d/c'd the same date.


----------



## sherryjean27

please help. Now I am confused.......


----------



## SCanterbury

No, even for the physician the patient is not being admitted and discharged the same date. The physician may not see them until the next morning but that still doesn't change the fact that they were admitted the night before. 

What is happening is that the physician is performing his initial evaluation on the same date as he will be discharging them, but the CPT Assistant is clear in stating that 99234-99236 is NOT to be used unless the patient was actually admitted by the facility and discharged on the same date. If the facility admit and discharge occurred on different DOS, then 99234-99236 is not an option, even if the physician performed his initial visit on the same date as discharging the patient.

Could we make an argument for why CPT should allow us to use 99234-99236? Sure. But our opinions don't trump CPT's official instruction.


----------



## melissatwy

*What was the final conclusion?*

Read this thread and left wondering what was the final conclusion?  
It seems there are two schools of thought:
1. admit and discharge on same day refers to calendar day that hospital shows patient admitted and discharged

or

2. admit and discharge on same day refers to calendar that physician saw patient and discharged them

Anyone have sources to support one or the other side?

I would appreciate any input.


----------



## SCanterbury

I posted a CPT Assistant above, written by the authors of CPT and considered authoritative, that discusses this EXACT situation.

It clearly says that you should NOT use the admit/discharge same day codes as these codes are only to be used when the hospital admission and discharge occur on the same date.

So when the admitting physician's initial visit occurs AFTER the actual date of admission (the next morning), and he discharges the patient, he has provided an Initial Hospital Care service + Discharge, but he has NOT provided E/M services for a patient actually admitted and discharge on the same date.

The article is clear, direct (addressing the exact issue in question), and from an authoritative source. Not trying to sound rude, but what more is needed?

Seth


----------



## colleen chiappone

*Colleen Chiappone, CPC*

I would appreciate clarification on the observation codes when our DR is NOT the admitting dr.  All documentation I have from Medicare MedLearn indicates "If another physician's evaluation is necessary, that physician (consultant) bills the office or other outpatient visit codes". 

Some of our physicians have been told that ALL Drs following the patient can bill the observation codes, not just the "Admitting" Dr. 

Thank you


----------



## Velna01

*Place of Service 23 with 99236*

Hello,

I'm trying to figure out if POS 23 is appropriate to bill with cpt 99236. I have researched this code using many different website and I find the information leads to any of the following: POS 21,22, or 23. I'd like to be sure if this is correct. Can anyone help? 

Scenario:
A NY state medicaid patient was seen by a ER physician who is billing for 99236 along with place of service 23. 

Thank you! 
Nancy V. CPC


----------



## sthomas@tnurology.com

I have a question in the same area, but different circumstance.  My doctors billing is not dictated by the hospital.  When one of our doctors was on call, the ER contacted him over the phone & our doctor ordered admission as out-pt to the hospital, did not see her face-to-face till later then same day when he discharged her.  Would this be billable only as an Observation Care Discharge??  99217 ??


----------

