Wiki How to bill physician consult while patient in acute care hospital on observation

[LeahJ123]

Hi everyone,
I am not understanding this scenario:
Patient is located in an acute care hospital, but is on observation status for three days then discharged. The physician was brought in on a consult, and is billing POS 22, 99252 for day 1, and for day 2 is billing POS 21 and 99232.

I thought the physician should bill for day 1 POS 22 and 99218-99220 and for day 2 bill POS 22 and 99211-99215.

A coworker is telling me that it should be paid as billed under "law of agency rules", meeting medical necessity.

I am not understanding why if the patient is in observation status, the physician is not billing observation codes then office code for day two since the patient is not technically "inpatient" in the acute care facility.
Can someone explain this to me please?
Thanks for your help!
Leah Johnson RN

 

[thomas7331]

I have no idea what your coworker means about "law of agency rules" and have never heard of this applying to coding scenarios - I think you'll have to get clarification from that person. A consultant is not acting as an agent, but even if they were I don't understand how that would apply to this situation in any way.

Per coding guidelines, this should be billed as observation care, not inpatient care. If the patient was never admitted to inpatient status, POS 21 would not be correct, and 99252 and 99232 would also be incorrect since those are both inpatient service codes. There would need to be a physician order in the medical record in order for the patient's status to be inpatient. Per CPT guidelines, physicians consulting for patients in observation should bill the outpatient consult code (99242) and subsequent observation care codes (99224-99226) for additional visits. For Medicare, and other payers that do not accept consultation codes, the outpatient codes 99201-99215 should be billed instead. Codes 99218-99220, per CPT and CMS guidelines, are reserved for the attending or supervising physician who is initiating the patient's observation care.