Oncology & Hematology Coding Alert

Not coding for the treating physician? Look to outpatient E/M codes.

In effect for nearly a year now, CPT®'s subsequent observation care codes have been something of a mystery since they were released, but CMS finally ended that by issuing clarifications about how to report these codes.

Pinpoint Services Included in 99224-99226

The codes in focus are:

• 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, Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: 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, Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: 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.

CMS notes that subsequent observation care pay includes "all the care rendered by the treating physician on the day(s) other than the initial or discharge date," according to MLN Matters article MM7405, with an implementation date of Nov. 28, 2011.

In addition to specifically referring to the "treating physician" in the above passage, the agency goes on to qualify that any other physicians evaluating or consulting on the observation care patient "must bill the appropriate outpatient service codes," and not the subsequent observation care codes. This eliminates prior confusion that existed about exactly who could report subsequent observation care.

MAC advice: WPS Medicare, a Part B payer in four states, put its advice in writing back in January, noting that "only the physician admitting the patient to observation care status may bill these codes," including the admission (99218-99220), subsequent observation (99224-99226), and discharge from observation (99217) codes. Anyone else seeing the patient while in observation care would bill using an office or other outpatient procedure code (99201-99215), as appropriate.

Tip: CMS expects use of the subsequent observation care codes to be infrequent, noting, "In the rare circumstance when a patient receives observation services for more than two calendar days, the physician will bill observation services furnished on day(s) other than the initial or discharge date using subsequent observation care codes."

To read the complete MLN Matters article, visit www.cms.gov/MLNMattersArticles/Downloads/MM7405.pdf.