Observation vs. Outpatient Help!!!


Flint, MI
Best answers
Scenario: Patient presented in the ER, ER physician did a work up and wanted to keep patient. Patient was taken to a different floor in the hospital. Cardiologist was called in for a 'consult' and then did a follow up/subsequent the next day. The patient was released prior to 72 hours and the hospital considered the status observation. What does the Cardiologist bill?

I have asked a couple of colleagues and their responses were split down the middle. Half of them said 99204 and 99213. The other half said the cardiologist should have billed subsequent observation codes. Both sides had valid points.

I do not have the CPT book on hand, so I am going off memory Please forgive my paraphrasing.

Some points:
1. The CPT book states (in the observation section) that the supervising physician is to bill these codes and other physicians see Office or Other Outpatient Consultation Codes (99241-99245) or subsequent Observation codes (dont remember codes). Since 99241-5 codes are null and void to most insurances, that leads to me believe that subsequent obs codes should be billed.

2. The CPT book states a patient is considered outpatient until the patient has been admiitted as inpatient (I believe under the Office or Other Outpatient Services section.) However, in the same section it states for observation, see observation codes.

3. Becasue the CPT book states (as in #1) other physicians see Office or Other Outpatient Consultation Codes (99241-99245). The 'or' is telling the coder to see Office (which is referring to 99203-99215) or Other Outpatient Consultation codes (99241-99245) or subsequent observation care codes. However, the entire section is named " Office or Other Outpatient" and because 99203-99215 was not actually referenced, the or is just quoting the section to find the codes.

I know different insurances will interpret this differently. However, I want to know as a coder, what is the correct way to code it.

I look forward to the input!
In your notes it is not clear as who did the initial observation care. If cardiologist was called in to see the patient who is already in observation status then Cardiologist can bill an office or outpatient consult 99241-99245 (hope this is not a medicare patient), on subsequent day cardiologist can bill an office or outpatient visit 99212-99215.
hope this helps...:) Rose