Oncology & Hematology Coding Alert

Question: A patient with hematological malignancy was given chemotherapy subsequent to which the patient returned with complaints the next day and was kept under observation. The observation lasted for about 9 hours. The medical records state that the patient was under level-three observation service. The admission and discharge are both documented for the same calendar day. The patient is covered under Medicare. How can we report for this service?

Ohio Subscriber

Answer: For Medicare, and payers who follow Medicare coding rules, you should report a single observation code for the observation service described. On the claim, report 99236 (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 comprehensive history; a comprehensive examination; and medical decision making of high complexity…) for this observation and since it exceeded more than 8 hours and was documented. These codes are based on service and, although there is a time factor involved, you cannot bill more of the same code based on the added time.

Less than 8 hours: For observations lasting less than eight hours on a single calendar day, Medicare wants you to report the appropriate code from the 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components…) code set.

More than 8 hours: For Medicare payers, you’ll pick from the 99234-99236 code set if the observation lasts more than eight hours on a single calendar day.

Note: For private payers, check the payer’s specific policies before reporting a 99218-99220 for a single-day observation of less than eight hours. Some payers could prefer you use 99234-99236.