I am billing for general surgery profee services and have always billed OP hospital POS with the 99202-99205 or 99212-99215 as appropriate for profee services whether in the ED or outpatient or observation hospital statuses. I am being told that I should be billing only observation codes for outpatient hospital or emergency department codes of 99281-99288 with a place of service emergency department if service provided in the ED. Further, I am being told that just because an E&M says outpatient or other outpatient visit it never may be used in the way I described above for patients that are not designated IP. Can you please weigh in on this right away! Thanks in advance!
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Wiki POS question for OP hospital vs Emergency codes
- Thread starter srpaul
- Start date
TThivierge
True Blue
Hi
Someone needs to tell you it is observation status and why. At my old hospital the attending doc who decide pt. from ER or outpt .surgery staying longer made notation/document it is observation status due to pt. complications or too ill to leave. After so many hours OP observation may turn into Inpt. status or pt. discharged. It should be documented so you can select correct CPT code..
I hope this data helped you
Lady T
Someone needs to tell you it is observation status and why. At my old hospital the attending doc who decide pt. from ER or outpt .surgery staying longer made notation/document it is observation status due to pt. complications or too ill to leave. After so many hours OP observation may turn into Inpt. status or pt. discharged. It should be documented so you can select correct CPT code..
I hope this data helped you
Lady T
amyjph
True Blue
I had to read your question a couple times. It seems like two different questions to me. One, which place of service is appropriate depending on the disposition of the patient? Two, which codes can be assigned to that place of service? Is that what you are asking?
This statement is a little confusing: "I should be billing only observation codes for outpatient hospital or emergency department codes of 99281-99288 with a place of service emergency department if service provided in the ED." You can't really use a blanket statement that you "should only bill observation codes for outpatient hospital POS". That doesn't make sense. You would code according to the documenation, disposition of the patient, who the attending is, CPT, and possibly the payer rules. It is possible that you would bill 99202-99205 for OP hospital POS and also possible for observation. However, if you are billing ED codes and the patient status was never anything but ED, you would use the ED POS and ED CPT.
The patient could be located in the ED "area" but their disposition could be admitted to observation (maybe there is no bed available, etc.). It goes back to the disposition of the patient. If you read the CPT instructions at the beginning of the Hospital Observation Services section, it explains this. Further, the instructions at the beginning of the Initial Observation Care and Emergency Department Services sections explain those.
The place of service would be assigned appropriately depending on the disposition of the patient.
You can also look to the CMS Manual for guidance: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf
CMS instructions do not always match other payers.
30.6.8 - Payment for Hospital Observation Services and Observation or Inpatient Care Services (Including Admission and Discharge Services) (Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11)
"All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes. For example, if an internist orders observation services and asks another physician to additionally evaluate the patient, only the internist may bill the initial and subsequent observation care codes. The other physician who evaluates the patient must bill the new or established office or other outpatient visit codes as appropriate."
30.6.11 - Emergency Department Visits (Codes 99281 - 99288) (Rev. 1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10) A. Use of Emergency Department Codes by Physicians Not Assigned to Emergency Department Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department.
This statement is a little confusing: "I should be billing only observation codes for outpatient hospital or emergency department codes of 99281-99288 with a place of service emergency department if service provided in the ED." You can't really use a blanket statement that you "should only bill observation codes for outpatient hospital POS". That doesn't make sense. You would code according to the documenation, disposition of the patient, who the attending is, CPT, and possibly the payer rules. It is possible that you would bill 99202-99205 for OP hospital POS and also possible for observation. However, if you are billing ED codes and the patient status was never anything but ED, you would use the ED POS and ED CPT.
The patient could be located in the ED "area" but their disposition could be admitted to observation (maybe there is no bed available, etc.). It goes back to the disposition of the patient. If you read the CPT instructions at the beginning of the Hospital Observation Services section, it explains this. Further, the instructions at the beginning of the Initial Observation Care and Emergency Department Services sections explain those.
The place of service would be assigned appropriately depending on the disposition of the patient.
You can also look to the CMS Manual for guidance: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf
CMS instructions do not always match other payers.
30.6.8 - Payment for Hospital Observation Services and Observation or Inpatient Care Services (Including Admission and Discharge Services) (Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11)
"All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes. For example, if an internist orders observation services and asks another physician to additionally evaluate the patient, only the internist may bill the initial and subsequent observation care codes. The other physician who evaluates the patient must bill the new or established office or other outpatient visit codes as appropriate."
30.6.11 - Emergency Department Visits (Codes 99281 - 99288) (Rev. 1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10) A. Use of Emergency Department Codes by Physicians Not Assigned to Emergency Department Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department.
Amy, thank you very much for sharing your knowledge and I'm sorry that my question was confusing. We are rarely the attending, almost always called to consult or evaluate in ED, OP and IP. I have been using the office or other outpatient visit codes correctly as you referenced above in 30.6.8 for observation and outpatient stay statuses. And from your ED reference 30.6.11, I've been coding those incorrectly by using the same office or other outpatient visit codes when the stay status has stayed ED thinking that they are still outpatient encounters. I appreciate you! I'll use this to hopefully convince my manager of the correct portions of my E&M coding and save my job.
amyjph
True Blue
It can be a very confusing concept to grasp. In some cases the payer may not follow Medicare and they actually want the observation codes regardless of if the provider was the attending or a consulting. I think it depends on the payer, some may not want the ED codes. I think in some cases it's provider's choice so you may not actually be incorrect in that. ED is technically "outpatient" since they are not admitted IP, but is it's own "thing". (If that makes any sense )
If you read the wording of: "30.6.11 - Emergency Department Visits (Codes 99281 - 99288) (Rev. 1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10) A. Use of Emergency Department Codes by Physicians Not Assigned to Emergency Department Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department." It says they MAY use but it's not necessarily mandatory (in my opinion).
Another thing to keep in mind is that if you are coding pro-fee for a consulting provider practice too quickly, the patient's status may change after you billed it. This can cause later take-backs or denials once the hospital claims are processed.
)If you read the wording of: "30.6.11 - Emergency Department Visits (Codes 99281 - 99288) (Rev. 1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10) A. Use of Emergency Department Codes by Physicians Not Assigned to Emergency Department Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department." It says they MAY use but it's not necessarily mandatory (in my opinion).
Another thing to keep in mind is that if you are coding pro-fee for a consulting provider practice too quickly, the patient's status may change after you billed it. This can cause later take-backs or denials once the hospital claims are processed.