Oncology & Hematology Coding Alert

Count the hours for single-day stays, or beware the consequences.

Physicians are admitting more patients than ever to observation status -- so government auditors will be scrutinizing these claims like never before.

Medicare restrictions have made many hospitals tighten the criteria for what constitutes an inpatient stay.Result: Some patients linger in observation care for longer than the average period -- in some cases up to two weeks, according to a Dec. 11, 2008, notice from the Center for Medicare Advocacy.

As hospital policymakers set standards regarding which patients qualify for observation care and which should be inpatients, you as a physician coder need to ensure that your observation coding practices are pristine.

Include Same-Day Office Visit in Observation

If your oncologist sees a patient in his office for dehydration, for example, and decides to subsequently admit that patient to observation status, you should not report both the office E/M (such as 99212, Office or other outpatient visit &) and observation code (such as 99218,Initial observation care, per day &).

Reason: If the provider sees the patient in the office and then sees the patient in observation, then the office visit rolls into the initial observation code, says Sherry Gann, CPC, with Shawnee Health Service.

Avoid Discharge Codes for 1 Day Visits

8 to 24 hours: If your oncologist admits a Medicare patient to observation status and discharges the patient on the same date, report a code from the 99234-99236 (Observation or inpatient hospital care & including admission and discharge on the same date &) range. You should not report a separate discharge code.

Note that Medicare says to use 99234-99236 when a patient has been admitted for observation care for a minimum of 8 hours, but less than 24 hours and discharged on the same calendar date (Medicare Claims Processing Manual, Chapter 12, Section 30.6.8, www.cms.hhs.gov/manuals/).

Less than 8 hours? The Manual states that when a patient is admitted for observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218-99220, shall be reported by the physician. The Observation Care Discharge Service, CPT code 99217, shall not be reported for this scenario.

Bill for Next Day or Later Discharge

If the physician sees a patient for observation care (such as 99220, Initial observation care, per day &) and discharges him on a different date, you can bill 99217 (Observation care discharge &) on the discharge date, says Rhonda Hardison, CPC, coder with the Head and Neck Center in Baton Rouge, La.

The Manual supports this method, instructing you to report the initial observation care with 99218-99220 and discharge on a different calendar date with 99217.

Watch for Adjustment to Inpatient Status

Inpatient: CPT instructs that once a patient is admitted you should no longer use the observation procedure codes; you should use the inpatient codes, says Kim French, CIRCC, of Crouse Radiology Associates in Syracuse, N.Y.

Observation visit: But when the patient is in observation, a physician billing a visit to the patient (such as an oncologist performing a consult for a patient in observation) must use outpatient/office visit codes, not inpatient codes.