Gastroenterology Coding Alert

Question: One of our physicians admitted a patient to the hospital at 11:30 a.m., and later that day another physician from our group discharged the patient (at 4:30 p.m.) The admitting physician wants to bill a 99223 and the discharge physician wants to bill a 99217. Which code(s) should each physician report?

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Answer: The answer to your question depends on several factors. First, you must determine whether the patient was admitted to inpatient status or to observation. That will help you at least review the appropriate code range. It appears that one of your physicians wants to bill an inpatient code (99223, Initial hospital care, per day, for the evaluation and management of a patient…) whereas the other wants to bill a code from the observation range (99217, Observation care discharge day management…). Therefore, it looks like even the physicians didn’t clearly understand whether the patient was in the observation unit or inpatient.

If you bill from the wrong section, it will impact you from not only a correct coding standpoint, but also possibly from a compliance standpoint, since a level three initial inpatient code reimburses approximately ten percent more than a level three initial observation code.

If you find that the patient was in observation care, the second issue you must consider is the amount of time that the patient spent in the hospital (five hours). When coding this case, your eyes may go to the 99234-99236 (Observation or inpatient hospital care… including admission and discharge on the same date…), but you should avoid this section if it is a Medicare patient.

Why? Medicare requires the patient to be in observation care for a minimum of eight hours to justify reporting this code.

In black and white: According to CMS Medicare Claims Processing Manual (Chapter 12, Section 30.6.8), “When a patient is admitted to observation status for less than 8 hours on the same calendar date, the physician shall report a code from CPT^® code range 99218-99220.” Therefore, if it’s an observation patient, you should report a code from the 99218-99220 series.

Important: No matter what code you select, you should only report one code to represent both physicians’ time with the patient, since they both work for your group and are the same specialty.

“Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician,” CMS says in Section 30.6.5 of Chapter 12 of the Medicare Claims Processing Manual. “If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.”

Looking ahead: In the Final Rule for 2019, CMS indicated it was going to change this policy and allow for such situations. This is usually implemented via instructions to contractors and a specific effective date. So for now, it is best to check with your own contractor to see if this situation is covered.