Otolaryngology Coding Alert

Additional time guides will supplement 99218-99220 descriptors beginning Jan. 1.

If you're barely familiarizing yourself with 2011 new codes for subsequent observation care 99224-99226, brace yourself for a couple of fresh reports about how to report these codes, and reimburse for your deserved dollars.

CMS Renders Finality To 99224-99226 RVUs

Current Procedural Terminology (CPT®) introduced codes for subsequent observation care, 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.); 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.); and 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.) beginning Jan. 1, 2011. During the public comment period, the American College of Physicians (ACP) questioned the relative values the Centers for Medicare and Medicaid Services (CMS) assigned for these codes. In July, however, the CMS released a clarification rendering the present relative values for 99224-99226 as final, according to the ACP Internist article "ACP disputes federal valuation of primary care observation codes" (see www.acpinternist.org/archives/2011/09/coding.htm).

CMS maintains that the following value units are final at the disputed levels, and will determine the payment levels for subsequent observation care under the Medicare fee schedule for 2011 and following years:

• 99224 -- 0.82
• 99225 -- 1.45
• 99226 -- 2.17

Note: The actual payment amount will change in 2012 if the conversion factor changes.

'Treating Physician' Gets Exclusive Rights To Use 99224-99226

CMS has also clarified that only treating physicians can report subsequent observation care. The agency 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. 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.

The clarification stems from prior confusion about exactly who could report subsequent observation care. You can check out the complete MLN Matters article, visit www.cms.gov/MLNMattersArticles/Downloads/MM7405.pdf.

Pick Out Appropriate Observation Code Based On Time

Hospital observation care codes 99224-99226 and 99218-99220/99217 apply to an otolaryngologist when a patient gets admitted to observation (as opposed to inpatient), and gets discharged either on the same day or on two calendar days.

"Should you base your code on counseling and/or coordinating care, you now can select your observation code based on time instead of the documented history exam and medical decision making," explains Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, NJ. For instance, the codes may apply to a trauma patient who needs stabilization before discharge; a patient who has an epistaxis and you do not want to send them home after the control of the bleed, so you admit them to observation; or an allergy patient who had an adverse reaction to their regular immunotherapy shot and you admit them for observation.

Tell the difference: If you're confused about the distinct functions of 99224-99226 and another set of observation codes 99218-99220/99217, remember that the difference lie on when the service is rendered/completed.

Codes 99224-99226 describe observation care for a patient who is admitted to and discharged from observation on the same calendar day. In this case you would use only one code to represent both services of the admission and the discharge from observation.

On the other hand, you would look at reporting 99218-99220/99217 when a patient gets admitted and discharged from observation on two calendar days. This time, you would report two codes -- one for admission to observation (99218-99220, New or established patient initial hospital observation care services), and one the next calendar day, when the patient is discharged (99217, Observation care discharge day management).

The difference between 99224-99226 and 99218-99220/99217 is that with the first set, the patient is admitted to and discharged from observation on the same calendar day. One code, 99224-99226 represents both services of the admission and the discharge from observation. With the second set of codes, the patient is admitted and discharged from observation on two calendar days. Two codes are used, one for admission to observation, 99218-99220 and one the next calendar day, when the patient is discharged, 99217.

99218-99220 Joins The Time Guide Bandwagon

Also for 2012, fresh time guides on the initial observation care codes 99218-99220 will make its debut come Jan. 1:

• 99218 -- ...Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit
• 99219 -- ...Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit
• 99220 -- ...Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit.

This will mirror the fact that these codes will feature typical times associated with them, just as subsequent observation care codes 99224-99226 already have since they were introduced. The CPT® committee's reason for including these codes may not be entirely apparent until the AMA's November CPT® Symposium, but the additional typical times could help you out when coding based on time.

"There are only two ways that you can use time as a basis for selecting an E/M code," says Cobuzzi." "If counseling/coordination of care takes up 50 percent or more of the visit, and if the code has a typical time associated with it. So by these codes now having a time reference, it sounds like we may have a way to reference time used if counseling or coordination of care takes up at least 50 percent of a visit. In addition, this could open the door to collecting for prolonged service times if the time the doctor spends exceeds 30 minutes more than the allotted time, and the visit notes are documented as such," Cobuzzi adds.