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Outpatient Observation 99234-99236

  1. Default Outpatient Observation 99234-99236
    Medical Coding Books
    Ok all my E/M friends, I need your help. I am having troubles understanding the 99234-99236. Here is my dilema.
    Now keep in mind I am billing for the physician, not the hospital.

    I have a patient that comes into the ER at 11:59PM on Monday 6th. The ER goes ahead and admits him to OPO on Monday the 6th. However, my Dr does not come in until Tuesday morning on the 7th to do his H/P. Well later that evening on the 7th, the Dr has decided to go ahead and discharge the patient.
    Now here is the problem.I have been told 2 different ways on how I should bill this.

    1st way: The dr can bill 99234-99236 since he didn't actually see and discharge the patient until Tuesday 7th.


    2nd way: Since the patient came into the ER the night before the only thing the Dr can bill is the 99218-99220 or 99217 because it has already crossed over the midnight mark. Therefor the Dr can only bill for Tuesday 7th 99218-99220 or 99217.

    Now I have searched and searched everywhere for proof on what to do, and I Have had 4-5 different opinions both different. Does anyone know what the AMA says about this? We have tried contacting them but never receive an answer. I need some input....real actual input...

    Last edited by VRcoder29; 04-13-2009 at 01:39 PM.

  2. #2
    Milwaukee WI
    Default The date the service is provided
    You code the service on the date the service was provided.

    In your scenario the physician saw the patient "initially" on the 7th; the physician happened to also discharge patient this same date of service.

    Because these two events cannot be billed separately on one date of service, you would appropriately use the 99234-36 (admit/discharge on same date of service) code to describe the services provided by the physician on this one date of service.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. Default
    I will be honest with you, that is what I think along with about 2 other coders, however the hospital is making us bill the discharge only. Their arguement is... the patient came in the night before, therefor since the dr didn't come in that night to see them they can't bill the 24 hour admit/discharge. The hospital is making us bill these with 99217 only. I think this is crazy, but I can't get proof from AMA to defend my case. All I seem to be getting are a bunch of opinions.
    So I can't code it properly because of the hospital....

  4. #4
    Milwaukee WI
    Default Why does the hospital have a say?
    I don't understand ... why does the hospital have any say in how the physician's services are coded?

    F Tessa Bartels, CPC, CEMC

  5. Default
    Because the Drs are all employed by the hospital and we have a auditor whom thinks that is how it should be done. Instead of the hospital listening to 3 certified coders, one being here longer that 25 years... they listen to an auditor who has been a coder no longer than 5 years.
    Honestly, I don't know what is going on, we just have to "follow" the rules and until I can get written proof from the AMA or our local medicare carrier we will continue doing the way the hospital wants us to. Some of the Dr's are even disagreeing, but it doesn't matter....because the hospital runs the show.
    Last edited by VRcoder29; 04-15-2009 at 05:25 AM.

  6. Default
    Anyone else out there have anything to help me?

  7. #7
    Default Per CMS

    "B. Policy: When a patient is admitted to observation status for less than 8 hours on the same calendar date, the physician shall report Initial Observation Care using a code from CPT code range 99218 – 99220. The Observation Care Discharge Service, CPT code 99217, shall not be reported for this scenario. When a patient is admitted for observation care and discharged on a different calendar date, the physician shall report an Initial Observation Care using a code from CPT code range 99218 – 99220 and CPT code 99217 for the Observation Care Discharge Service. When a patient is admitted to observation status for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, the physician shall report the Observation or Inpatient Care Services (Including Admission and Discharge Services) using a code from CPT code range 99234 – 99236, and no additional discharge service. Physician documentation shall meet the evaluation and management (E/M) documentation requirements for history, examination and medical decision making. In addition, the physician shall document he/she was physically present and that he/she personally performed the observation care services. The physician shall personally document the admission and discharge notes and include the number of hours the patient remained in observation care status. In rare circumstances when a patient is held in observation status for more than 2 calendar days, the physician shall bill a visit from CPT code range 99211 – 99215 (Office or Other Outpatient Visit) furnished before the discharge date."

    The physician is doing all their work on the same calendar date so I would think this would apply.
    Hope this helps your case

    Laura, CPC
    Last edited by LLovett; 04-17-2009 at 11:44 AM.

  8. Default
    Thanks for the info Laura, I already had this info. BUT here is the loophole. The hospital says the patient came into the hospital the night before, therefor since the patient was not seen by their doctor in the hospital the night before the Dr can only bill the 99217 ( that is the hospital definition. ) I agree with everyone, I think it is based on what the Dr does not when the patient walks in the door.

    Let me ask everyone does this sound logical to you? *note this is what the hospital thinks*

    A patient walks in April 22 at 11:59pm, therefor since they walked in 1 minute before the day changes over it automatically puts them in over the next day or for 2 days. Although there is no way for the Dr to be there that very minute, therefor the only thing our doctor can bill for a patient who is in and out on April 23rd is 99217. That isn't even logical to me.

    Shows how powerless we are sometimes..

  9. Question 99234-99236
    Ok ladies, I also have this problem but I am looking at it differently. I want to know if the code requires two face to face visits. The description doesn't say this is required. The provider goes in on the seventh and does the work for the initial and does the work for the discharge.....all in one face to face visit, can you then bill the 99234-99236. Do you know if your provider is having two face to face visits or just one?

  10. #10
    Evansville Indiana
    Default observation
    Ask the auditor for documentation to support their position.

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