Inpatient Facility Coding & Compliance Alert

Question: A patient was admitted to outpatient observation and remained there for two days. On day three, her status was changed to inpatient admission (where she remained through her C-section delivery and discharge). The Colorado Medicaid system does not allow for an outpatient visit within 24 hours of an admission. How do I bill for the patient’s six days of care, considering her two different status circumstances?

Colorado Subscriber

Answer: You’ll need to report several different codes to explain the situation as her time in the hospital progressed.

Day 1: Bill the appropriate observation care code from the range 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components …).

Day 2: Bill the appropriate subsequent observation code from the range 99224-99226 (Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components …).

Day 3: If this is the day the patient is admitted from observation care to inpatient status, the physician should report only the initial inpatient admission code (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components …) with modifier AI (Principal physician of record). Do not bill any observation care codes for this day, per CPT® instructions. Remember that the initial hospital care code reported by the admitting physician should include the services related to the observation status services he provided on the same date of the inpatient admission. If a different physician admitted the patient, you’ll still choose an initial hospital visit code but won’t need modifier AI.

Following days: Any day when the physician simply visits the patient but doesn’t provide another service, report the appropriate choice from 99231-99239 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components …). Only report one subsequent care code for each day.

Delivery day: Report the appropriate CPT® code for the surgeon who performed the C-section. It’s important to note that if the same physician who admitted the patient or who provided subsequent care performed the C-section, then you should not bill any E/M service codes prior to the delivery date. Any pre-operative E/M care is included in the surgery code.