Radiology Coding Alert

Plus, refresh your knowledge of admitting physician requirements.

If you don’t have a firm grasp of hospital care guidelines on the off-chance that your radiologist needs to report inpatient or observation care services, your claim could be heading for a denial. The struggle is certainly real when it comes to differentiating the following hospital 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, by taking a few key steps, you’ll be able to sort out the differentiating features between respective services. Check out these clinical examples and expert guidance.

Compare, Contrast 99234-99236 With Other Inpatient Services

When considering the fundamental differences between inpatient 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.

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.

Time: How you’ll report observation care services depends on how your radiologist documents the stay. For instance:

• More than eight hours: 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.
• Greater 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.
• 48-72 hours: 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.
• Excess of 48-72 hours: A patient admitted to inpatient status 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

Note: Admitting providers must get the status of the patient from the hospital census in order to determine cording. This means a patient could stay overnight in an inpatient bed and still be coded with a set of observation 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, you or your radiologist should inquire from the hospital’s census to find out the patient’s official status. In other words, a patient who 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, your radiology practice has to stay on top of patient status with the hospital, which can be 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. Similarly, other providers seeing inpatient status patients should bill the subsequent inpatient E/M codes 99231-99233.

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.