Question Observation Discharge Day After Pre-scheduled (Elective) Outpatient Procedure/Surgery

mcauffman86

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Saint Joseph, MI
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I work for a Cardiology practice and our providers will order observation services for a patient after an elective (pre-scheduled) outpatient procedure is performed such as a heart cath (no global period) and keep the patient overnight for monitoring and then will discharge them the next day.

We usually will bill an observation discharge day (99217) for the day after when they are discharged. However we have a couple of payers that deny the discharge code stating that an observation discharge cannot be billed without an initial observation care code (99218-99220). We do not usually bill for the initial observation care day since it was a pre-scheduled and elective procedure and our providers usually see the patient in the office a few days before and that is when the decision is made to the schedule the procedure.

I cannot seem to find any documentation stating that an observation discharge day cannot be billed without an initial observation care code. Traditional Medicare pays the discharge code without an initial observation day just fine, so I am not sure if this is just a payer issue or if we truly should not be billing for the discharge and it is included in the payment for the procedure even though these procedures do not have a global period.

Is anyone else having this same issue or can direct me on where to find clarification on proper billing of observation discharge after elective outpatient procedures?
 

ellis3350

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Galloway, OH
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You may want to check and see if the patient is truly OBS or just OP in a bed. If just OP, then I'm thinking 99212 or 99213 would be more like the code you should be using depending on documentation.
 
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We bill Observation by the hour using HCPCS G0378. If the patient had 3 hours of observation we would code G0378 X3. Of course you would have to follow admit/dc Observation orders. Hope this helps! :)
 

RyanRaichCPC

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Local Chapter Officer
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Lawrence, KS
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We bill out our hospitalistd initial observation services even during an elective procedure. They are helping to monitor a post-op patient and making medical decisions as to how their post-operative care should be handled in conjunction with other providers, therefore deserve to be reimbursed for the initial observation. To me it just makes sense that Observation Discharge codes would be denied without having an initial observation code billed, per common sense. Remember under-billing is the same as over-billing and all services should be reported. This is probably being denied as well because there are observation admit/discharge on the same day CPTs that are reportable with POS 22.

From CMS:
Who Can Bill for Observation Status:

Only the physician admitting the patient to outpatient observation care (or a member of the same group with the same specialty) may bill the observation CPT procedure codes. This includes the admission (99218 - 99220), subsequent observation (99224 - 99226), and discharge from observation (99217) CPT procedure codes. Anyone else seeing the patient while in observation care would bill using an office or other outpatient procedure code 99201 - 99215 as appropriate. The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.8 discusses observation care.
 
Last edited:

cgaston

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In general, a separate E&M is only payable if treatment is for something unrelated to the surgery.

IMHO I think the carrier is denying because the reason for the observation stay is strictly due to recovery from the surgery. The only way you will get reimbursed for a separate E&M is if the visit for something unrelated to the surgery.
 

heart123

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food for thought
This non-face-to-face time for office services-also called pre- and postencounter time-is not included in the time component described in the E/M codes. However, the pre- and post-non-face-to-face work associated with an encounter was included in calculating the total work of typical services in physician surveys.
This non-face-to-face time for office services-also called pre- and postencounter time-is not included in the time component described in the E/M codes. However, the pre- and post-non-face-to-face work associated with an encounter was included in calculating the total work of typical services in physician surveys.
Thoughts please
 

Tami_F

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Detroit
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IMHO I think the carrier is denying because the reason for the observation stay is strictly due to recovery from the surgery. The only way you will get reimbursed for a separate E&M is if the visit for something unrelated to the surgery.
Agreed. If everything is routine and there are no complications, clearing the patient for discharge is part of the work involved in the scheduled procedure.
 
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