Inpatient Facility Coding & Compliance Alert

Question: Our provider admitted a patient for observation, but documentation of initial admission had not been done. We are using office visit codes 99211-99215; however, the patient is seen the following two days in observation. Can we bill subsequent observation codes? Or does the follow-up observation need to be billed with office visits codes as well? 

Minnesota Subscriber

Answer: When the patient is in observation status and the documentation of admission cannot be confirmed, send a query to the facility asking for documentation of admission.

If you receive inpatient documentation, then report the appropriate inpatient codes (99221 – 99223).

Office visit codes (99211 – 99215) should not be billed since you are not sure whether the patient was discharged from the observation status.

Initial observation codes (99218 – 99220) should be billed for initial observation and subsequent observation codes (99224 – 99226) should be billed for patient seen for two days of continued observation. After two days of observation status, the patient needs to be discharged or admitted as inpatient.

Advice: A good idea is to address this with the physicians so that they are documenting enough for you to report the initial visit.