Pulmonology 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 that 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."

Section 15504 of the Medicare Carriers Manual advises differently.  This states, "In the rare circumstance when a patient is held in observation status for more than two calendar dates, the physician must bill subsequent services furnished before the date of discharge using the outpatient/office visit codes."

Thus, if a private payer instead suggests that 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. 

Remember: This coding advice applies to physician coding only, not hospital coding.

Answers for You be the Coder and Reader Questions were reviewed by Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia; and Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy and Critical Care at Emory University School of Medicine in Atlanta.