Oncology & Hematology Coding Alert

Question: A hematologist sees a patient for a consult on his first day in observation and then sees the patient again the following day, still in observation. Which CPT codes should I report?

California Subscriber

Answer: For both visits you should use the appropriate outpatient codes based on the hematologist's documentation.

Even the physician who admits the patient to observation uses office/outpatient codes when the patient is in observation for subsequent dates, but prior to the discharge date, according to the Medicare Claims Processing Manual (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf). Other physicians who visit the patient should use office/ outpatient codes, as well. Inpatient codes are not appropriate for patients in observation.

Support: Consider the following manual excerpts:

• "Payment for an initial observation care code is for all the care rendered by the admitting physician on the date the patient was admitted to observation. All other physicians who see the patient while he or she is in observation must bill the office and other outpatient service codes or outpatient consultation codes as appropriate when they provide services to the patient."

• "In the rare circumstance when a patient is held in observation status for more than 2 calendar dates, the physician [who admits the patient to observation] shall bill a visit furnished before the discharge date using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital."