Wiki Observation/Inpatient Codes for 2023?

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tori.a

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I desperately need clarification on the new initial/observation care codes for 2023. Now that the observation codes are being merged with the initial inpatient hospital codes, do consulting/specialist physicians still have to use the office/outpatient codes when they see a patient in the hospital who is under observation status? We are a urology practice so we are rarely the admitting doctor so we normally bill outpatient codes (99202-99215) when we see a patient who is under observation in the hospital. So with the new codes, are the rules the same, that only the admitting physician can bill the new observation codes?
 
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Hi there, the short answer: Not unless another urologist from your practice has seen the patient.

Under the new guidelines when a provider of a different specialty/sub-specialty/group sees the patient for the first time during a stay that provider will report the appropriate initial visit code. This is in the CPT 2023 manual and the guidelines the AMA released earlier this year: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
 
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Hi, thanks for the reply. I've read the AMA guidelines but they don't specify if the new merged codes (99221-99223, 99231-99233) can be used by a provider who is not the admitting physician. I did receive an answer from Maggie Mac who stated: Per the CMS Federal Register, see page 528 which states that CMS is not changing their billing guidance for observation care when multiple providers see a patient. Therefore, per this guidance, the consultation provided by the Urologist for a patient admitted to observation status by another physician, should be reported using the outpatient codes - 99202 - 99215. Use place of service 22 on the claim to indicate observation status.

Hopefully there will be better clarification on this going forward!
 
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We are also not changing policies affecting billing, at this time, when multiple practitioners furnish E/M services to the same patient on the same day (such as the policy in Chapter 12 of the Medicare Claims Processing Manual (IOM 100-04), section 30.6.8.A, which specifies that while the practitioner who orders the observation care for a patient may bill for observation care, other practitioners providing additional evaluations for the patient bill their services as O/O E/M codes.) We are also not currently making any changes to current policy on the use of the AI modifier.

CMS is not extending the new guidelines to specialists visiting hospital outpatients, Hirsch points out. These visits will continue to be coded with office and other outpatient visit codes instead of the simplified hospital visit codes.
 
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I'm still so confused on what codes to use. Been using 99221-99223 for inpt and 99218-99220 for Obs. Too much conflicting info to understand what I should be using for 2023
 
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bill2doc said:
I'm still so confused on what codes to use. Been using 99221-99223 for inpt and 99218-99220 for Obs. Too much conflicting info to understand what I should be using for 2023
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What is confusing specifically? Medicare and CPT do not always align on what to use. The difference is the admitting physician versus consulting physicians (usually this is what confuses people).
 
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I have a question on this as well. So when a patient is in OBV status we report appropriate I/P EM code however do I change the POS to reflect OUT PATIENT or does it remain as I/P? Thank you.

Also Is the 3 year rule now in effect? Meaning that if my physician has seen a patient in the hospital within 3 years I can NO LONGER code Initial Visit it has to be a Subsequent visit I/P E/M? Thank you
 
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Per Maggie Mac, we are to refer to the CMS Federal Register:
Per the Federal Register (attached), see page 528 which states that CMS is not changing their billing guidance for observation care when multiple providers see a patient. Therefore, per this guidance, the consultation provided by the Urologist for a patient admitted to observation status by another physician, should be reported using the outpatient codes - 99202 - 99215. Use place of service 22 on the claim to indicate observation status.
Whether or not this changes or is clarified by CMS/Medicare going forward is yet to be determined as this question keeps coming up and the Federal Register is the only guidance we have at this time for 2023 changes.

So if a specialist sees a patient who is under Observation status in the hospital and their insurance is Medicare or follows Medicare guidelines, we are to use office/other outpatient E/M codes 99212-99205. The three year rule still applies (meaning you cannot bill a new patient code 99202-99205 if the provider has seen the patient in the last 3 years. This doesn't apply to initial hospital codes 99221-99223 which are able to be coded once per admission).
 
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Thank you, so My understanding on this is If the specialist see's a new patient in OBV status bill Office EM new still and if the patient has been seen within the last 3 years bill a subsequent code Observation status only, the 3 year rule does not apply to Inpatient Coding? Correct?
 
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surfergirl said:
Thank you, so My understanding on this is If the specialist see's a new patient in OBV status bill Office EM new still and if the patient has been seen within the last 3 years bill a subsequent code Observation status only, the 3 year rule does not apply to Inpatient Coding? Correct?
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As of right now, if the patient's insurance is Medicare or follows Medicare guidelines, do not use the 99221-99223, 99231-99233 for patients under Observation unless you are the admitting provider. Medicare still considers Observation codes to be billed by the admitting physician only. So whether new or established, we will use the Office/Other outpatient codes 99201-99205, 99212-99215 as a specialist if the patient is under observation. The three year rule does not apply to the inpatient initial codes (which can be billed once per admission) however you cannot for example bill 99222 on Monday and then bill a new patient code 99201-99205 in the office afterwards.
 
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Cindy01 said:
Admitting provider billing observation with 99222-99238 POS 22, Medicare is denying for wrong POS???
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Unfortunately the place of service problem is pretty widespread. It appears that many payers and MACs didn't update their systems in time to account for the code changes. In other words, your claim is correct, the MAC is wrong.
 
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surfergirl said:
Thank you for your reply I am still receiving Denials from Commercial Payors for Observation status (attending physician) billing 99223 etc
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If your payer publishes a list of systems/claims processing errors check there to see if they're working on the problem. If not, contact the payer directly. It could be they aren't aware of the problem yet.
 
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I just addressed this last week. the information is in CMS Processing Manual 100-04, Chapter 12; 30.6.8.A; Who Can Bill For Observation Services. This rule has not changed for now. So if another provider is admitting to observation care, and a specialist sees patient during this status, then office visits are appropriate. I am not having any denials. With all this said, I am still watching for any changes in the future. Hope this helps. ACW
 
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I work at an OB/GYN office and unless it's a delivery we rarely are the admitting doctors. I read the CPT guidelines as each type of providers (i.e. urology, primary care, ob/gyn) each get their own initial visit inpatient/observation codes. We have been getting paid on our claims.
 
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