Wiki Proper coding for patients seen by a specialist during their observation stay

[quinn1234@tampabay.rr.com]

I just wanted to confirm with the panel the correct way to bill for an exhisting pateint who was seen in the hospital during the observation stay portion prior to being formally admitted as an inpatient. We are an oncology practice and one of our oncologist was asked to consult on a patient for Hematology reasons, while the patient was still registered as being in observation. The physician obliged and saw the patient, but marked teh encounter as an initial inpatient visit (99221-99223).

Per CMS guidelines (PUB 100-04 Claim Processing Manual, Transmittal 2282, section 30.6.8 Payment fo Hosptial Observation Services and Observation of Inpateint Care Services (including admission and discharge), "Payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient’s observation services began. 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."

Unfortunately, it does not go into detail on how to code if the patient being seen was already and exhisting patient of the consulting physician. Since we are told to use the appropriate outpatient codes (99211-99215, 99201-99205), the question was asked which would be the more appropriate code type of code, exhisting or new patient? I think an argument could be made for both code types, but my gut feeling is that we are bound by the 3yr rule when using the outpatient codes. Is this the more prudent way to approach these scenarios?

Greg Quinn, CPC, CPPM, CHONC

 

[megg1100]

Observation

The three year rule does apply when billing outpatient codes in the hospital. I'm assuming this is a Medicare patient and consult codes cannot be billed? In the section of the CPT book for initial observation care it states " To report services provided to a patient who is admitted to the hospital after receiving hospital observation care services on the same date, see notes for initial inpatient care." For the consult, I would bill for initial hospital care.

 

[quinn1234@tampabay.rr.com]

Observation

"The three year rule does apply when billing outpatient codes in the hospital. I'm assuming this is a Medicare patient and consult codes cannot be billed? In the section of the CPT book for initial observation care it states " To report services provided to a patient who is admitted to the hospital after receiving hospital observation care services on the same date, see notes for initial inpatient care." For the consult, I would bill for initial hospital care."

Megan,

Thank you for your reply. Yes this is for Medicare patients who are known to the practice where the specialist is called in to render and opinion for a potentially new admission and is seen while still in the observation stay. I figured the 3 year rule would apply by wanted to confirm my interpretation was correct. Again, thank you for your response.

Greg Quinn, CPC,CPPM,CHONC