Oncology & Hematology Coding Alert

The OIG is watching observation coding, so be sure you are, too.

Last month's issue of Oncology and Hematology Coding Alert reported the addition of three new "subsequent observation care" codes. Here are the definitions so you can get a feel for what these codes will require:

• 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. 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 responding inadequately to therapy or has developed a minor complication.Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.
• 99226 -- ... A detailed interval history; A detailed examination; Medical decision making of high 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 unstable or has developed a significant complication or a significant new problem.

Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit.

Caution: "The OIG workplan for 2011 indicates that the Plan includes review of the appropriateness of observation payments and medical necessity. Up until 2011, observation subsequent day care was reported with established outpatient visit CPT codes 99211-99215 [Office or other outpatient visit for the evaluation and management of an established patient ...].

With the inauguration of these new codes, it will provide a very specific mechanism to track the length and level of care for observation services that providers report," says Kelly Loya, CPC-I, CPhT, managing consultant for Los Angeles-based Sinaiko Healthcare Consulting.