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99217 and Consulting Physician

  1. Default 99217 and Consulting Physician
    Medical Coding Books
    The physicians in my practice see a lot of patients in Observation status. We are trying to correct claims from 2009 prior to CMS stopping payment on consultation codes. My question is concerning who can actually bill 99217, only the admitting physician or can the consulting physician bill it also?

    Sceniaro: Dr A consults specialist Dr B on Mrs Q. Dr B bills the appropriate outpatient consult code frin 99242-99245. The next day Dr B sees the patient again and states that the patient is ok for d/c therefore d/c the patient from his service.

    Would Dr B bill 99217 even though he is the consulting physician and not the admitting because he is also d/c from his service? Or would Dr B bill an outpatient code 99212-99215 based on documentation?

    Simple way of putting it would be -- Does 99217 apply to the consulting physician also, or is only the admitting physician allowed to bill it?

  2. #2
    From AMA's Principle of CPT

    "Only the physician admitting the patient to observation status may report the initial observation care code. For observation encounters provided by physicians other than the admitting physician, other E/M codes are reported, as appropriate.....Code 99217 is used to report observation care discharge day management. This code is used by the physician to report the final examination of the patient, discussion of the observation stay, instructions for continuing care, and preparation of discharge records......"

    From this link

    Contractors pay for initial observation care billed by only the physician who ordered hospital outpatient observation services and was responsible for the patient during his/her observation care. A physician who does not have inpatient admitting privileges but who is authorized to furnish hospital outpatient observation services may bill these codes

  3. Default
    Thank you for your prompt reply. I have read the Medicare Claims Processing Manual in regards to billing for observation services, it just is never clear if only the admitting physician can bill 99217. Do you think that it is a safe assumption that if it is not explicitly stated that 99217 is billed only by the admitting physician, then yes, my consulting physician may bill it when he is seeing the patient for the last time and stating ok for discharge?

    Just need a cocrete answer to back myself up when meeting with my administrator.

  4. #4
    Milwaukee WI
    Default Was care transferred?
    Was care of the patient transferred to Dr B? If YES, then Dr B can bill for the discharge from observation. (And, by the way, if that was the case, then he probably didn't perform a consultation on the previous day, either.)

    If NO, then only the attending/admitting physician can discharge the patient.
    Dr B would use the established patient visit codes 99211-99215 (as per documentation, of course).

    F Tessa Bartels, CPC, CEMC

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