Reader Question:
Observation After ERCP
Published on Mon Oct 01, 2001
Question: Usually after an endoscopic retrograde cholangiopancreatography, our gastroenterologists will keep a patient in observation for 12 to 24 hours but not bill for their services during this time. However, we may keep the patient for as long as 48 hours after the ERCP and are not sure how to report for those extended stays. In some cases, the patient may end up being admitted to the hospital. How should we report these E/M services?
New Jersey Subscriber
Answer: Medicare and CPT disagree somewhat on which codes to use when a patient is admitted to observation. Medicare revised its national policy for observation care codes and published the changes in the Nov. 1, 2000, edition of the Federal Register:
When a patient is admitted for observation care for more than eight hours and is discharged on the same calendar day, 99234-99236 (observation or inpatient hospital care) should be reported.
When a patient is admitted for observation care for less than eight hours and is then discharged on the same calendar day, 99218-99220 should be used to report the admission, and no discharge code should be reported.
When a patient is admitted for observation care and discharged on a different calendar day, 99218-99220 (initial observation care) should be used to report the admission and 99217 (observation care discharge) to report the discharge.
If the patient is held in observation for more than two calendar days, Medicare's national policy states that any E/M services provided after the day of admission and before the day of discharge should be reported using the outpatient/office visit codes (99211-99215). The time is based on when the patient is admitted to observation, not when the procedure was completed. A day is defined as a calendar day. A patient could be admitted to observation at 11:30 p.m. on Monday and discharged at 6:30 a.m. on Tuesday -- that would qualify as an admission on one calendar day and a discharge on a different day even though the patient had been in observation for only seven hours.
CPT guidelines on observation care allow gastroenterologists to bill the higher-paying observation care code (99234-99236) whenever a patient is admitted and discharged from observation on the same day and not just when the patient has been there for over eight hours. Many private payers who follow CPT, as well as local Medicare carriers who opt not to follow the national policy, may be using this guideline.
Medicare revised its national policy on inpatient admissions to the following:
When a patient is admitted to inpatient hospital care for more than eight hours and is then discharged on the same day, 99234-99236 should be reported.
When a patient is admitted to inpatient hospital care for [...]
