Otolaryngology Coding Alert

Compare and contrast 3 code ranges common to otolaryngology.

If the varying sets of hospital care guidelines leave you scratching your head, you’re in good company. The struggle is certainly real when it comes to differentiating the following inpatient care code ranges:

• 99221-99223 (New or Established Patient Initial Hospital Inpatient Care Services)
• 99218-99220 (New or Established Patient Initial Hospital Observation Care Services)
• 99234-99236 (Observation or Inpatient Care Services (Including Admission and Discharge Services))

Fortunately, there’s a few measures you can take to properly distinguish between these services. With the help of some clinical examples and expert guidance, you’ll be on your way to coding future hospital care services with ease.

Read on for a breakdown of the fundamental differences between inpatient care services.

Compare, Contrast 99234-99236 With Other Inpatient Services

When considering the fundamental differences between hospital services codes, you should first take note that 99234-99236 represents the services of an initial hospital service and a discharge service performed on the same calendar date for a patient admitted to observation. This means your documentation must reflect the exact times for admission and discharge. Keep in mind that all patients that are designated as observation patients are considered to be in POS 22 (On Campus-Outpatient Hospital) for outpatient.

To consider: A patient in observation care may be in an inpatient hospital bed. They also can be located in the emergency department (ED). They do not have to be in a separate area designated as observation.

To bill 99234-99236, you must have a statement that shows the stay for observation care was greater than eight hours but less than 24 hours. If the admission is greater than 24 hours, then the code you would use is determined on the status of the patient. Patients in the hospital for 48-72 hours can be placed into observation status and as a result their initial care would be coded 99218-99220. Each subsequent day’s care for patients in observation is coded 99224-99226 and discharge from observation is 99217 (Observation care discharge day management…). A patient admitted to inpatient is expected to remain in the hospital in excess of 48-72 hours and they would be admitted with initial hospital care codes 99221-99223

Coder’s note: Admitting providers must get the status of the patient from the hospital census in order to determine coding. This means a patient could stay overnight in an inpatient bed and still be coded with a set of observation evaluation and management (E/M) codes so long as the hospital census categorizes the patient encounter as such.

Problem: One known issue with observation versus inpatient care is determining what services the admitting and discharging provider can and cannot report. To remedy this, it’s recommended that the provider or office staff inquire from the hospital’s census to find out the patient’s official status. A patient that starts out as observation because it is assumed that they will be quickly discharged may end up being upgraded to inpatient. An inpatient who is doing better than expected may be changed to observation because they are being discharged in time to qualify for observation. As a result, the practice has to stay on top of patient status with the hospital. It is understood that this is difficult. Even practices owned by the hospitals have a difficult time with this concept.

Learn Admitting Physician Requirements

Keep in mind that for observation admissions, follow-up, and discharge (in addition to inpatient initial visits and discharges), only one physician can be the admitting physician of record. Furthermore, only the admitting physician can report code ranges 99218-99220, 99234-99236, 99224-99226, 99217, 99221-99223 (with the AI [Principal physician of record] modifier for Medicare Part B), and 99238-99239. For observation patients, any other providers should use outpatient E/M code range 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). Similarly, other providers seeing inpatient status patients should bill the subsequent inpatient E/M codes 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components…).

Note this exception: “Medicare Part B allows consultants to report an initial inpatient code when performing an inpatient consultation,” explains Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey. “There is no other mechanism in which you can code and bill for a consultation for any other patient status. In these instances, consultants can report the appropriate code from range 99221-99223. That’s why Medicare Part B instructs the admitting physician of record to add modifier AI to their initial hospital care codes — so that Medicare knows that they are the admitting physician and not a consultant,” Cobuzzi adds.

Consider 2 Useful Examples

Example: If the otolaryngologist admits a Medicare Part B patient to inpatient for acute sialadenitis for intravenous (IV) antibiotics (comprehensive history, exam, and MDM of moderate complexity), they will report 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components…) with modifier AI for parotiditis. The patient is diabetic so the provider asks the endocrinologist to perform a consultation on the patient. The consulting provider will typically report 99221 for the consult with a diagnosis of type 1 diabetes mellitus with hyperglycemia.

Example: If otolaryngologist X sees a patient in the morning and otolaryngologist Y, who is covering for the first doctor, sees the same patient in the evening, the combined notes for each service will result in only one subsequent hospital visit code. However, if two physicians from different specialties see the patient for different diagnoses (i.e., otolaryngologist seeing patient for parotiditis and endocrinologist seeing patient for diabetes), then both may bill a subsequent hospital visit based on that physician’s note and the medical necessity of the service.