Neurosurgery Coding Alert

Length of observation period is key to accurate reporting.

When your surgeon places a patient under observation instead of requesting an admission for treatment, you will need to keep a watch on the number of hours of observation. "Physicians should be aware that hospitals, based on compliance software, may change a patient's "admission status" to observation rather than inpatient hospitalization, sometimes without the physician's knowledge," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. Follow the tips below to report observations with convenience and accuracy.

Learn Timelines for Same Day Discharge

When you report observation care services, you need to look hard at the time the patient was placed under observation.

For patients placed under observation for a period lasting more than eight hours but discharged within the same day, you need to report observation codes 99234 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually the presenting problem[s] requiring admission are of low severity), 99235 (...Medical decision making of moderate complexity...moderate severity) and 99236 (...Medical decision making of high complexity...high severity) depending on severity of the patient's condition.

Example: Here is a coding scenario

A 66 year old patient with a fainting episode was admitted to observation care at 8:30 am for treatment and to watch for any further progression of symptoms or deteriorating condition. She responds to therapy and is discharged at 7 pm the same night. You would code 99236 for the admission and discharge on the same day. You code ICD-9-CM code 435.9 (Unspecified transient cerebral ischemia) for the ischemic attack. In order to correctly document and report 99234-99236, the physician must personally include the duration of observation in the note, as well as evidence of each component of these codes, the admission component and the discharge component (i.e., two visits).

Note Criticality of 8-Hour Mark for Medicare

If the patient is released within 8 hours, you cannot report 99234-99236 since the length-of-stay requirement was not met.

Instead, you need to use 99218 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s]and the patient's and/or family's needs. Usually, the problem[s] requiring admission to "observation status" is of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit), 99219 (....Medical decision making of moderate complexity...Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit) or 99220 (....Medical decision making of high complexity...Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit).

"The Observation Care Discharge Service, CPT® code 99217 (Observation care discharge day management), shall not be reported for this scenario," says Mary I Falbo, MBA, CPC, President of Millennium Healthcare Consulting, Inc., Lansdale, PA.

Use Subsequent Observation Care Codes for Multiple Days

"If the patient is admitted to observation care and discharged on another day, use 99218-99220 for the initial day and 99217 for the discharge day," says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

For all subsequent days of observation care (in between the initial observation care day and the discharge day), you need to report 99224 (Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit), 99225 (...An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity... Physicians typically spend 25 minutes...) or 99226 (... A detailed interval history; A detailed examination; Medical decision making of high complexity...Physicians typically spend 35 minutes...). You can use 99217 to report services rendered on the day of discharge.

Note: You cannot use 99217 to report services rendered if the patient has been admitted for observation and discharged within the same calendar day.

Example: Below is another coding scenario:

A 69-year-old with a mild acute episode of transient loss of consciousness is admitted to observation care by the neurosurgeon for treatment. He responds to treatment and is discharged home on the next day. Because of the documented complexity of his condition, concomitant medical conditions, and decision making, you code 99220 for the initial day and 99217 for the discharge day. You code ICD9-CM code 435.9 for the ischemic attack. The patient due to concomitant medical conditions was also seen by a cardiologist on the day of discharge who coded a 99204 (Office or other outpatient visit for the evaluation and management of a new patient...) for the visit and used ICD-9-CM code 402.10 (Benign hypertensive heart disease without heart failure) for his diagnosis of hypertensive heart disease without heart failure.

Be Sure About Who Can Bill for Observation Services

"Only the attending physician reports codes 99218-99220," reminds Falbo. "The attending of record writes the orders to admit the patient to observation; indicates the reason for the stay; outlines the plan of care; and manages the patient during the stay," she adds. "The attending reports the initial patient encounter with the most appropriate initial observation-care code, as reflected by the documentation. If other consultants attend to the patient under observation, billing for the specialist (consultation) service depends upon the payor."

"For a non-Medicare patient whose insurance pays for consultation codes, the specialist reports an outpatient consultation code 99241-99245 (Office consultation for a new or established patient....) for the appropriately documented service," says Falbo. "Conversely, Medicare no longer recognizes consultation codes, and specialists must report either a new patient visit code 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient...) or established patient visit code 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient...) for Medicare beneficiaries."

Crucial detail: Reporting a new vs established patient visit will depend upon whether or not the patient has received a face-to-face service from the physician/surgeon/group within the last three years, in any service location.