Primary Care Coding Alert

Look at date, time when choosing between 99217-99220 and 99234-99236

You'll avoid observation claim denials if you focus on the service's date(s) and length.

Because two series exist for observation care services, many coders aren't sure how the codes differ. "When should I use observation codes 99217-99220 and 99234-99236?" asks Maria Tarullo, coding specialist for James A. Clark, MD, in Howell, N.J.

Experts say you can choose the correct code set if you follow these three rules.

1. Report 99217-99220 for 2-Day Stay

You can easily pick the appropriate observation care code set if you look at the claim's service dates. "If the observation care occurs on two calendar dates, you should use 99217-99220," says Betsy Nicoletti, CPC, a coding education speaker and consultant, and owner of Medical Practice Consulting based in Springfield, Vt.
 
How it works: A family physician (FP) admits a patient to observation care at 10 a.m. on Feb. 12 and discharges the patient on Feb. 13. "You would bill 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient ...) on Feb. 12 and 99217 (Observation care discharge day management ...) on Feb. 13," Nicoletti says.

2. Consider Coding 1-Day Stay as 99234-99236

In contrast, you'll usually use 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...) when an FP provides observation care on a single service date. "You should report 99234-99236 for same-date observation admission and discharge, according to CPT's rules," Nicoletti says.

Example: An FP admits a patient to observation status at 1 a.m. on Feb. 12, and discharges the patient at 12 p.m. the same day. "In this case, you would assign 99234-99236," Nicoletti says.

Before coding 99234-99236, double-check that the FP's chart note supports billing an admission and discharge. "Documentation should show two entries,"  Nicoletti says.

Here's how: One paragraph should describe the observation care including observation initiation, care plan supervision, and periodic patient assessment. Another entry should detail the discharge services the physician performs, such as final examination, instructions to patient and caregivers, and discharge documentation preparation.

3. Check Time Before Billing Same-Day Admit, Discharge

Depending on your patient's insurance company, you may, however, code short same-day observation care services with 99218-99220 (Initial observation care), instead of 99234-99236 (Observation including admission and discharge on the same day). "Medicare requires a patient to be in observation care for at least eight hours before you can use a same-day observation care admission and discharge code (99234-99236)," says Belinda M. Robinson, CPC, coding specialist at Valley Health Care in Mill Creek, W.V.

Medicare way: An FP admits a Medicare patient to observation status at 12 p.m. on Feb. 12 and discharges the patient at 6 p.m. Because the observation care service lasted less than eight hours, CMS will pay only the observation admission code (99218-99220), says Brett Baker, a third-party payment specialist with the American College of Physicians. "CMS thinks a patient discharged from observation that soon after admission is less complex than a patient who is in observation more than eight hours before being discharged."

You don't have to follow Medicare's "Eight-Hour Rule" unless a payer requires you to. But whether you adopt the policy for all insurers is up to you and your FPs to decide. "Because we're under increased government scrutiny as a federally qualified health center (FQHC), we always try to follow Medicare's rules," Robinson says.