Pulmonology Coding Alert

8 hours may make or break your 99218 reporting

Your pulmonologist's service date(s) and length hold the key to helping you avoid future denials for your observation cases.

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 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: Your pulmonologist 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 your pulmonologist 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: Your pulmonologist 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 your pulmonologist's chart note supports billing an admission and discharge. "Documentation should show two distinct services," Nicoletti says.

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

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

Depending on the insurance company, you may, however, code short same-day observation care services with 99218-99220, instead of 99234-99236.
 
"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," says Belinda M. Robinson, CPC, coding specialist at Valley Health Care in Mill Creek, W.V.

Medicare way: Your pulmonologist 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 is less than eight hours, CMS will pay only the observation admission code, 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 pulmonologists to decide. "Because we're under increased government scrutiny as an FQHC, we always try to follow Medicare's rules," Robinson says.