Pediatric Coding Alert

Choose between 99217-99220 and 99234-99236 based on date, time

If you let your observation care service dates and times steer your code selection, you can tackle the problems that many coders face in selecting an appropriate observation care code.

Because two code series exist for observation care services, many coders aren't sure how the codes differ. "When should I use observation codes 99217-99220 and 99234-99236?" asks Maria Tarullo, coding specialist for James A. Clark, MD, in Howell, N.J.

Experts say you can choose the correct code set if you follow three simple rules.

99217-99220 Describe 2-Day Stay

You can easily pick the appropriate observation care code set if you look at the claim's service dates. "If the observation care occurs on two calendar dates, you should use 99217-99220," says Betsy Nicoletti, CPC, a coding education speaker and consultant, and owner of Medical Practice Consulting based in Springfield, Vt.
 
Example: A pediatrician admits a patient to observation care at 10 a.m. on Feb. 12 and discharges the patient on Feb. 13. "You would bill 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient ...) on Feb. 12 and CPT 99217 (Observation care discharge day management ...) on Feb. 13," Nicoletti says.

Capture any observation care days between the admission and discharge day with an outpatient office visit code. Even though observation codes parallel inpatient hospital care, CPT considers observation care an outpatient service. "If a patient spends more than two days in observation care, use 99211-99215 for additional days prior to discharge," says Maggie Mac, CMM, CPC, CMSCS, consulting manager at Pershing, Yoakley & Associates in Florida.

Use 99234-99236 for 1-Day Stays

In contrast, you'll usually use 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...) when a pediatrician provides observation care on a single service date. "You should report 99234-99236 for same-date observation admission and discharge, according to CPT's rules," Nicoletti says.

Scenario: A pediatrician admits a patient to observation status at 1 a.m. on Feb. 12 and discharges the patient at 12 p.m. the same day. "In this case, you would assign 99234-99236," Nicoletti says.

Before coding 99234-99236, double-check that the pediatrician's chart note supports billing an admission and discharge. "Documentation should show two entries," Nicoletti says.

Here's how: One paragraph should describe the observation care, including observation initiation, care plan supervision and periodic patient assessment. Another entry should detail the discharge services the physician performs, such as final examination, instructions to patient and caregivers, and discharge documentation preparation.

Time May Affect Same-Day Admit, Discharge Code

Depending on your patient's insurance company, you may, however, code short same-day observation care services with 99218-99220, instead of 99234-99236. "Medicare requires a patient to be in observation care for at least eight hours before you can use a same-day observation care admission and discharge code (99234-99236)," says Belinda M. Robinson, CPC, coding specialist at Valley Health Care in Mill Creek, W.V.

Impact: Private payers may use Medicare's "Eight-Hour Rule." "If an insurer pays according to the fee schedule, the company will probably follow Medicare's guidelines," Mac says.

How the rule works: A pediatrician admits a patient to observation status at 12 p.m. on Feb. 12 and discharges the patient at 6 p.m. The patient's insurer pays based on Medicare's observation guidelines.

Because the observation care service lasted less than eight hours, the insurer will pay only the observation admission code, says Brett Baker, a third-party payment specialist with the American College of Physicians. "CMS thinks a patient discharged from observation that soon after admission is less complex than a patient who is in  observation more than eight hours before being discharged."

You don't have to follow Medicare's "Eight-Hour Rule" unless a payer requires you to. But whether you adopt the policy for all insurers is up to you and your pediatricians to decide.