Pulmonology Coding Alert

Question: Our pulmonologist admitted a patient to the hospital at 11:30 a.m. A different pulmonologist, also from our practice, discharged the patient at 4:30 p.m. The admitting physician wants to bill an inpatient code, while the discharging physician wants to bill an observation code. Which is correct?

Alabama Subscriber

Answer: The answer here depends on a number of factors, including whether the patient was admitted as an inpatient or observation, and the length of time the patient spent during the stay.

You could report a patient admitted and discharged by physicians in this scenario with 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...), which covers both inpatient and observation statuses. However, this requires the patient stay to last at least eight hours on one calendar day.

But if the patient was admitted less than eight hours on the same day, you would bill only one service, using 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient ...). The pulmonology group could only bill 99218-99220 and 99217 (Observation care discharge day management ...) when billing for a stay that spans two calendar days, and the corresponding physician service was provided on each day.

Why? Medicare and payers who follow its guidelines abide by the CMS decision that when “a patient receives observation care for less than eight hours on the same calendar date,” the physician should report “from CPT^® code range 99218-99220.” (Source:  https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2282CP.pdf)