Neurology & Pain Management Coding Alert

Effective Jan. 1, 2001, Medicare has revised its payment policy for observation and inpatient hospital care services when the patient is admitted and then discharged more than eight hours later on the same day. Despite the policys revision, however it is still at odds with CPT coding instructions, which state that 99234-99236 (observation or inpatient hospital care) should be used to report observation or inpatient hospital care services for patients admitted and discharged on the same date of service.

CPT doesnt differentiate by time and doesnt require the stay to be eight hours or more to bill 99234-99236, says Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J., that consults with several neurology practices. If the stay goes into the next calendar day, then CPT says to report both an admission and a discharge.

According to Kathleen Mueller, RN, CPC, CCS-P, a physician reimbursement specialist in Chester, Ill., in some cases, the insurance carrier will not authorize an inpatient admission, but will authorize an observation stay because it costs less. Any subsequent admission to the hospital would have to be authorized by the carrier and then billed accordingly, Mueller says. A neurologist may admit a patient to observation or inpatient hospital care services for less than a day for a variety of reasons. For example, a patient who is being treated for a sports-related concussion (850.0) may be admitted to observation for persistent low-grade headaches (784.0). Also, if the patient is suffering from poor attention and concentration after a concussion, a neurologist may admit the patient to observation.

99234-99236 Pays More Than Initial Care Codes

As stated in sections 15504.b and 15505.1(c) of the Medicare Carriers Manual, the previous policy had allowed the reporting of only an admission code for observation/inpatient hospital stays when the patient is admitted and discharged on the same day.

Under the new policy, however, neurologists may code 99234-99236 for observation or inpatient hospital stays when the patient was admitted and then discharged more than eight hours later on the same day. Because these observation or inpatient hospital care codes include both an admission and a discharge in their descriptions, they have higher relative value units (RVUs) than the initial observation or hospital care codes.

With the new Medicare policy, for example, a neurologist may admit a patient for observation, take a comprehensive patient history, perform a comprehensive examination and do medical decision-making of moderate complexity. The patient is discharged more than eight hours later, but on the same day. The neurologist may then report 99235, which has a 2001 transitioned facility RVU of 4.74. Under the old policy, only 99219, which has a 2001 transitioned facility RVU of 3.06, could have been reported.

Using 99234-99236 for All One-day Stays

Many local Medicare carriers follow these CPT coding instructions and allow neurologists to report 99234-99236 when a patient is admitted and discharged on the same day, regardless of the amount of time spent in observation or inpatient hospital care. Other carriers have local medical review policies (LMRP) that stipulate a more generous payment policy. The LMRP of Empire Medicare Services of New Jersey states, 99234-99236 should be reported when observation care is provided to patients admitted and discharged on the same date of service.

Nationwide Medicare Services, the carrier for Ohio and West Virginia, has a policy similar to that of Empire Medicare Services of New Jersey, except that it extends its LMRP to include the inpatient and outpatient setting. The Nationwide policy states, 99234-99236 are acceptable when the patient is admitted and discharged from either an inpatient or outpatient setting on the same date, which is the same as the CPT instructions.

Because the carriers have final discretion over their payment policies, it is unclear whether the local payers will revise their policies to be in line with the new national ruling or maintain their LMRPs as now stated.

Local carriers have been given the discretion to interpret national policy, Brink says, which is why neurologists should always check their local carriers policy before reporting the service.

Document Time Spent When Using 99234-99236

The new national ruling also requires neurologists to document the length of time spent in observation care or inpatient hospital status to report 99234-99236. In addition, the neurologist must meet the existing requirements for documenting the patients medical history, the results of the physical examination and the level of medical decision-making that occurred during the admissions process.

New National Policy for Observation Care Codes As published in the Nov. 1, 2000, edition of the Federal Register, the revised national Medicare policy for observation care services is as follows: When a patient is admitted for observation care for more than eight hours and is then discharged on the same day, 99234-99236 (observation or inpatient hospital care) should be reported. When a patient is admitted for observation care for less than eight hours and is then discharged on the same day, 99218-99220 (initial observation care) should be used for the admission, and no discharge code is necessary. When a patient is admitted for observation care and discharged on a different date, 99218-99920 (initial observation care) should be used to report the admission, and 99217 (observation care discharge) for the discharge. New Policy for One-day Inpatient Hospital Stays According to the previously cited edition of the Federal Register, the revised national Medicare policy for inpatient hospital care services is as follows: When a patient is admitted for inpatient hospital care for more than eight hours and is then discharged on the same day, 99234-99236 has an admit and discharge component (observation or inpatient hospital care) and should be reported. When a patient is admitted for inpatient hospital care for less than eight hours and is then discharged on the same day, 99221-99223 (initial hospital care) should be used for the admission, and no discharge code should be reported. When a patient is admitted for inpatient hospital care and discharged on a different date, 99221-99223 should be used to report the admission, and 99238-99239 (hospital discharge day management) for the discharge.