Pediatric Coding Alert

Question: I've heard that I can bill the "middle" day of observation as an outpatient office visit, such as 99212-99215. My supervisor says that we cannot get any reimbursement for that middle day. Do you have any documentation that would support our position?

Maine Subscriber

Answer: The AMA recommends you report the second day of a three-day stay in observation care with 99499 (Unlisted evaluation and management service), according to CPT Assistant's April 1996 Q&A Section. "However, you should check with the third-party payer because they may have policies that dictate how to code the second day."
 
Thus, if a private payer instead suggests you code the second day as an outpatient service, you may follow its guidelines and report 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) as appropriate. Otherwise, you should stick with the AMA-backed 99499.
 
The payer may not cover the second day based on observation duration policies. Generally speaking, observation services are 24 hours or less in duration. In rare cases, a pediatrician may extend the observation stay beyond 24 hours.
 
Remember: This coding advice applies to physician coding only, not hospital coding.