Cardiology Coding Alert

Extra:  Learn how to use Medicare's '8-hour rule'

If your cardiologist treats a Medicare patient, you should choose your observation code by focusing on two factors: the date of your claim, and the patient's length of stay.

Medicare's eight-hour rule outlines what codes you should report based on whether the patient's stay lasts more or less than eight hours.

In a nutshell: "When my cardiologist admits a patient and discharges her from observation on the same day, and she was there for more than eight hours, I report 99234-99236 [Observation or inpatient hospital care (including admission and discharge)]," says Jessica Carriveau, a coder at Cardiology Associates of Green Bay Ltd. in Green Bay, Wis. "If the patient was at the hospital for less than eight hours, I just bill the initial observation codes (99218-99220)."

Try Your Hand

Apply the eight-hour rule to the following examples:

Example 1: A patient presents to the emergency department (ED) with chest pain (786.50). The cardiologist admits the patient for observation on May 31 and discharges from observation status on June 1.

Because the observation and discharge were on different dates, you should code the encounter as follows:

• 99219--Initial observation care, per day

• 99217--Observation care discharge.

Example 2: Another patient presents to the ED suffering from claudication (440.21, Atherosclerosis of native arteries of extremities, with intermittent claudication). A cardiologist admits her to observation in the morning and discharges her late that night (during the same calendar day). In this scenario, you should use one of the 99234-99236 codes, depending on the level of service provided that the medical documentation supports.

Financially, Medicare's coding rule for short observation stay may make sense. Medicare "views a same-day observation discharge more than eight hours after the admission as equivalent in work" to an admission and discharge on different dates, says Brett Baker, a third-party payment specialist with the American College of Physicians.

Payment: You'll collect approximately the same Medicare reimbursement for an extended same-day observation admission and discharge as one that occurs on subsequent days.

Codes 99234-99236 reflect 3.58-5.89 relative value units and reimburse at an unadjusted Medicare rate of $135.67-$223.22, according to the 2006 National Physician Fee Schedule Relative Value File. Medicare pays about the same total amount ($138.33-$228.52) for a two-day observation stay using 99218-99220 (1.78-4.16 RVUs) and 99217 (1.87 RVUs).

You should challenge any insurer that adopts Medicare's observation care coding guidelines but doesn't reimburse 99234-99236 about the same as 99218-99220 and 99217. "If a payer follows the fee schedule policies, the company should pay you based on that scale," says Maggie Mac, CMM, CPC, CMSCS, consulting manager at Pershing, Yoakley & Associates in Florida.

Example 3: The cardiologist admits a patient with shortness of breath, fatigue and chest tightness to observation, but he stays less than eight hours. You should not report a discharge code and rely solely on 99218-99220, depending on your cardiologist's documentation.