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Pulmonology Coding Alert

Get Ready to Earn $115 for Observation Care

Published on Wed Apr 28, 2004

Experts show when to choose 99219 instead of 99214

Reporting established patient codes 99212-99215 when your pulmonologist evaluates a patient during observation care could be costing your practice $70 a session. To earn the reimbursement you deserve, you should choose hospital observation codes 99218-99220 when appropriate.

Understand When to Use 99219

You should report hospital observation codes (for example, 99219, Initial observation care, per day, for the evaluation and management of a patient ...) when your pulmonologist admits the patient to observation, maintains responsibility for that patient during the stay, and provides the initial E/M service, says Beverly Roy, CPC, CCP, a professional coder at Summit Medical Associates, a multi-specialty medical facility that offers pulmonary and internal medicine care in Hermitage, Tenn.

Key points: When the physician sees the patient in observation but is not managing the patient's care, you must report the appropriate outpatient codes (for example, if the physician treats an established patient, use the 99212-99215 series).

Example: A patient presents to the physician with chest pain (786.5x) and wheezing (786.07). Suspecting emphysema 492.8 (Other emphysema), the pulmonologist sends the patient to a hospital's observation unit. If your physician evaluates the patient during observation that same day, and he assigns that patient to observation status, you should report 99218 (Initial observation care ...). Observation care includes "all evaluation and management services provided by the supervising physician" while the patient is in observation status on the same day of service, according to CPT 2004.

The bottom line: By capturing this service correctly, you can expect higher reimbursement than if you had assigned 99214, for example. Medicare pays $115 for 99219, based on national averages, but Medicare pays only $86 for 99214 (Office or other outpatient visit for the E/M of an established patient ...).

Know How to Document the Initial Observation

To best document the observation, include the following in the medical record:

  •  the date and time the observation began
  •  the treatment the physician will provide while the patient is in observation (for example, 94060, Bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]) 
  •  nursing and progress notes prepared by the physician while the patient was in observation status, in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.

    Count Hours for Same-Day Admits, Discharges

    The keys to choosing the right code in this situation are to count the hours the patient stays in observation, the time of admission and discharge, and the date of service, Roy says.

    Careful: If the patient stays in observation status for less than eight hours on the same day, you should report 99218-99220. Also, you can't report discharge code 99217 (Observation care discharge day management) for observations of less than eight hours, Roy says.

    Tip: But if the observation lasts more than eight hours, you should report 99234-99236 (Observation or inpatient care services), according to Medicare guidelines. These codes include admission and discharge services provided on the same date. And if you report one of these codes, you can expect better reimbursement than if you used 99218-99220.

    For instance, Medicare pays $140 for 99234, based on national averages.

    Get Paid for Discharges
     
    When the pulmonologist discharges the patient on the day following admission, you can bill 99217, which reimburses about $70 nationally, in addition to 99218-99220 for the admission day reported on the previous day.

    Remember that to report a discharge code -- such as 99217 -- the physician must actually provide a face-to-face encounter and participate in the discharge service, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, coordinator of HIM certificate programs at Clarkson College in Omaha, Neb.

    Trouble: The pulmonologist states, "Observation of patient until 10 a.m. tomorrow. If no recurrence of problem, we can discharge patient at that time." In this situation, the physician will not be able to bill separately for 99217, because he didn't perform a service on the day of discharge, Bucknam says.

    Solution: Your physician admits a patient for the  following day; the physician discharges the patient after an evaluation. You could bill 99218 for care on Monday, and 99217 for the Tuesday discharge.

    When to Rely on Inpatient Codes

    If the physician sends a patient to inpatient care before the end of the day on which the hospital admitted the patient, you will use initial hospital care codes 99221-99223 instead of observation codes. On average, 99221-99223 pay about the same as observation codes, so you will not lose reimbursement when you report initial inpatient care.

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