Medicare and Observation Subsequent Status

krystle8402

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I want to make sure I understand this correctly. If I have a Medicare patient who lets say was admitted July 1 as an OBS, still in the hospital on July 2, and July 3, then discharges July 4 as an OBS. For July 2 and 3rd, since it's a Medicare patient, am I supposed to bill the subsequent visits as a 99212-99215 instead of the OBS subsequent visits 99224-99226? I was reading in the AAPC Survival guide how we should do that, and I have been using 99224-99226 for OBS subsequent visits for all patients.
 

krystle8402

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I did some more research on CMS' website, and it looks like they do recognize 99224-99226 for the admitting provider. However, for the doctor who is not the admitter, they would need to code 99221-99215.
 
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I want to make sure I understand this correctly. If I have a Medicare patient who lets say was admitted July 1 as an OBS, still in the hospital on July 2, and July 3, then discharges July 4 as an OBS. For July 2 and 3rd, since it's a Medicare patient, am I supposed to bill the subsequent visits as a 99212-99215 instead of the OBS subsequent visits 99224-99226? I was reading in the AAPC Survival guide how we should do that, and I have been using 99224-99226 for OBS subsequent visits for all patients.

The first problem you're going to run into is that the observation lasted more than 3 days. MC expects a pt to either be discharged or admitted to inpt status within that time frame, so that additional 4th day would likely get denied, probably for lack of medical necessity.

For the first day, July 1, the provider who made the decision to admit to obs would bill an admit code, 99218, 99219, or 99220. Any other services provided that day such as an office visit, or if the admit occurred during an encounter like from the ER, are inclusive to the admit code and cannot be billed separately. The worked performed during those other encounters can be counted when leveling the admit code, you just can bill them separately.

July 2 would bill subsequent care codes 99234, 99235, 99236

July 3 would normally get billed as discharge, 99217, which again is all inclusive of any services provided that day.

July 4 will get denied. I've read many places that you can try billing a subsequent care code for the 4th day, but I've never seen that work personally.

MC only comes into play when a consult is request. Because MC does not recognize consult codes, you have to use an office visit code instead. But again, if that consult happened the same day as the admit or discharge, it's kind of questionable whether it'd get paid.

If the pt is discharged from obs and admitted inpt, then you wouldn't use the 99217, rather you'd use an initial hosp inpt code.
 

krystle8402

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The first problem you're going to run into is that the observation lasted more than 3 days. MC expects a pt to either be discharged or admitted to inpt status within that time frame, so that additional 4th day would likely get denied, probably for lack of medical necessity.

For the first day, July 1, the provider who made the decision to admit to obs would bill an admit code, 99218, 99219, or 99220. Any other services provided that day such as an office visit, or if the admit occurred during an encounter like from the ER, are inclusive to the admit code and cannot be billed separately. The worked performed during those other encounters can be counted when leveling the admit code, you just can bill them separately.

July 2 would bill subsequent care codes 99234, 99235, 99236

July 3 would normally get billed as discharge, 99217, which again is all inclusive of any services provided that day.

July 4 will get denied. I've read many places that you can try billing a subsequent care code for the 4th day, but I've never seen that work personally.

MC only comes into play when a consult is request. Because MC does not recognize consult codes, you have to use an office visit code instead. But again, if that consult happened the same day as the admit or discharge, it's kind of questionable whether it'd get paid.

If the pt is discharged from obs and admitted inpt, then you wouldn't use the 99217, rather you'd use an initial hosp inpt code.


Thank you for your response. Wouldn't the subsequent care codes be 99224-99226?
 
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