Hospital Obs Discharge

BethUnkel

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I recently took over a billing spot and I the previous biller was not billing for Obs Discharge...she states that we can not bill for that... can someone please explain this to me? I don't see why our doctor could not bill for this.. I am currently taking classes to become a biller...any information or documentation would be VERY helpful!!!
 

cgaston

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The only thing I can think of is if your doctor performed 10 or 90 day surgical services during the admission then the discharge would be included.
 

BethUnkel

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Thank y'all! Seems the previous biller just didn't feel like billing it out. :(
 
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What codes are you using here? Was there a procedure performed at that time or at some point in the immediate past? Was it a same day admit/discharge?
 

BethUnkel

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The code that was being used was a 99218 only... even if they were there for more than one day. It is my understanding that for an obs patient is admitted then discharged on same day you use 99234-99236. If patient is put in for obs one day and then discharged the next(or a day other than initial obs date) then you use the 99217 as the discharge code. No these patients did not have a procedure performed recently.
 
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The code that was being used was a 99218 only... even if they were there for more than one day. It is my understanding that for an obs patient is admitted then discharged on same day you use 99234-99236. If patient is put in for obs one day and then discharged the next(or a day other than initial obs date) then you use the 99217 as the discharge code. No these patients did not have a procedure performed recently.

This might help...
If a patient is admitted to observation status, the provider who decided to admit the patient to obs status will report the initial care code (99218-99220). Here's where it can get messy; the admitting provider isn't necessarily the provider who will be continuing the care. For example, a patient presents to the ED and the ED physician decides to admit the pt to observation. The ED physician would then report only the admit code (99218-99220). The E/M charges for the ED service are considered inclusive to the admit code. Obviously the ED physician isn't going to continue care (more likely than not), because he/she has to go back to their department and continue treating other patients coming into the ED. The ED physician admits and that's the totality of their participation, so they won't code for sub care days or discharge. The same applies to a situation where a pt is seen by their PCP in his/her office and the PCP decides to admit the patient to the hospital. The PCP can't bill for the office E/M if he/she is the one who decides to admit the patient. The PCP can only bill the admit charge. In this case, the PCP may be the one who continues care during observation status, but not necessarily. If the PCP sends the patient to the ED for further evaluation, and the ED physician admits the patient, the ED physician bills the admit code and all other E/M services for that day are considered inclusive and can't be billed separately, including the office visit. These types of situations are what might cause a provider to only bill an admit code and nothing else. Essentially, it's all about who makes the decision to admit the pt to observation status. If they don't continue care, they have nothing else to bill for. The care is transferred to the provider who will be overseeing the patient during the obs stay; then he/she will be able to begin billing on the following subsequent day.

Example 1: Pt is seen in the ED on Monday; the ED provider decides to admit the pt to observation the same day, Monday; the ED provider bills 99218 (or anything in that initial code range) for that DOS, Monday, and not the ED services. The care is then transferred to the primary provider who will be overseeing the patient. He/she can begin billing on Tuesday, using a subsequent care code 99224 (or anything in the 99224-99226 range) for that DOS, Tuesday. The patient is discharged from observation on Wednesday, so the supervising physician will then bill 99217. 99217 includes ALL activities for that date (Wednesday), including any other E/M services provided by any other provider. So you'd end up with the ED provider billing 99218 for Monday, the supervising provider bills 99224 for Tuesday, then bills 99217 on Wednesday.

Example 2: Same situation as above except the patient is discharged on Tuesday, so the ED admitting provider bills Monday's 99218 and the supervising physician bills 99217 for Tuesday.

Example 3: Same situation as above except the patient is admitted to inpt on Tuesday by the supervising physician. The ED provider bills Monday's 99218, the supervising provider bills 99221 (or any code from 99221-99223) for Tuesday's inpt admit (again, no other E/M services can be billed, including discharge from observation).

One thing to keep in mind is that the admitting provider MAY INCLUDE any services they provided prior to the admission when leveling their admit code.

Aside from same day admit/discharge, the only situations in which you cannot bill the discharge 99217 that I can think of are if the patient's care was transferred and is no longer under your provider's care; your provider decided to admit but nothing else was performed by him/her (such as the ED physician example); a supervising provider discharged the patient and the services of your provider (who would then not be the supervising provider), would be inclusive of the discharge by the supervising provider's 99217; the patient was moved from observation to inpatient...

Nonetheless, if your provider made the decision to admit, but did not participate any further in the care as the supervising provider, i.e. a transfer of care was made, then he/she would not bill for any E/M services beyond the admission, including the inability to bill for the discharge day 99217.

If there is more information that you can provide, that might help me narrow it down further, if need be.
 

BethUnkel

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Local Chapter Officer
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This might help...
If a patient is admitted to observation status, the provider who decided to admit the patient to obs status will report the initial care code (99218-99220). Here's where it can get messy; the admitting provider isn't necessarily the provider who will be continuing the care. For example, a patient presents to the ED and the ED physician decides to admit the pt to observation. The ED physician would then report only the admit code (99218-99220). The E/M charges for the ED service are considered inclusive to the admit code. Obviously the ED physician isn't going to continue care (more likely than not), because he/she has to go back to their department and continue treating other patients coming into the ED. The ED physician admits and that's the totality of their participation, so they won't code for sub care days or discharge. The same applies to a situation where a pt is seen by their PCP in his/her office and the PCP decides to admit the patient to the hospital. The PCP can't bill for the office E/M if he/she is the one who decides to admit the patient. The PCP can only bill the admit charge. In this case, the PCP may be the one who continues care during observation status, but not necessarily. If the PCP sends the patient to the ED for further evaluation, and the ED physician admits the patient, the ED physician bills the admit code and all other E/M services for that day are considered inclusive and can't be billed separately, including the office visit. These types of situations are what might cause a provider to only bill an admit code and nothing else. Essentially, it's all about who makes the decision to admit the pt to observation status. If they don't continue care, they have nothing else to bill for. The care is transferred to the provider who will be overseeing the patient during the obs stay; then he/she will be able to begin billing on the following subsequent day.

Example 1: Pt is seen in the ED on Monday; the ED provider decides to admit the pt to observation the same day, Monday; the ED provider bills 99218 (or anything in that initial code range) for that DOS, Monday, and not the ED services. The care is then transferred to the primary provider who will be overseeing the patient. He/she can begin billing on Tuesday, using a subsequent care code 99224 (or anything in the 99224-99226 range) for that DOS, Tuesday. The patient is discharged from observation on Wednesday, so the supervising physician will then bill 99217. 99217 includes ALL activities for that date (Wednesday), including any other E/M services provided by any other provider. So you'd end up with the ED provider billing 99218 for Monday, the supervising provider bills 99224 for Tuesday, then bills 99217 on Wednesday.

Example 2: Same situation as above except the patient is discharged on Tuesday, so the ED admitting provider bills Monday's 99218 and the supervising physician bills 99217 for Tuesday.

Example 3: Same situation as above except the patient is admitted to inpt on Tuesday by the supervising physician. The ED provider bills Monday's 99218, the supervising provider bills 99221 (or any code from 99221-99223) for Tuesday's inpt admit (again, no other E/M services can be billed, including discharge from observation).

One thing to keep in mind is that the admitting provider MAY INCLUDE any services they provided prior to the admission when leveling their admit code.

Aside from same day admit/discharge, the only situations in which you cannot bill the discharge 99217 that I can think of are if the patient's care was transferred and is no longer under your provider's care; your provider decided to admit but nothing else was performed by him/her (such as the ED physician example); a supervising provider discharged the patient and the services of your provider (who would then not be the supervising provider), would be inclusive of the discharge by the supervising provider's 99217; the patient was moved from observation to inpatient...

Nonetheless, if your provider made the decision to admit, but did not participate any further in the care as the supervising provider, i.e. a transfer of care was made, then he/she would not bill for any E/M services beyond the admission, including the inability to bill for the discharge day 99217.

If there is more information that you can provide, that might help me narrow it down further, if need be.

danskangel313 - Thank you so much!!! This was VERY informative!!! We are a very small office in a VERY small town... so our doctor usually does is own admit for input and obs so this is very helpful!!! Would you happen to have any documentation to back this up? ( so I can show my doctor ) Again THANK YOU!!! Your answer was very helpful and easy to understand!!!!
- Beth
 
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