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Thread: Observation Coding

  1. #1

    Default Observation Coding

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    Established patients seen in hospital under observation status, regardless whether we are the admitting or the consulting. I believe the correct code set to use is from the 99211-99215 series, not 99201-99205. Could someone lend some clarification?


  2. #2
    Join Date
    Apr 2007


    If your physician is the admitting for observation services, you would use initial observation care code (99218-99220) and then 99217 on the date of discharge. I thought I read that the AMA stated that if the patient was receiving observation services for 48 hours and since there is not a subsequent observation care code for the second day if they are not discharged---that for this situation you would bill 99499.


    I would reveiw the above link for guidance for billing Medicare

    If a consultation was requested of your doctor from the admiting. You would bill 99241-99245 for a Non-Medicare payer. If Medicare is the carrier or a replacement plan that follows their guidelines then like you said you would use the three year rule on determine whether the patient was new or established and bill outpatient follow up codes if the patient had been seen by the physician or a physician of the same speciality of the same group within the last three years.

  3. #3


    When the patient is admitted on Observation status & discharged on same day:
    ----Use code from 99234-99236

    If patient in hospital overnight for observation but less than 48 hrs:
    ----1st day: 99218-99220
    ----2nd day: 99217

    If observation stay longer than 48 hrs:
    ----1st day: 99218-99220
    ----2nd day: 99212-99215
    ----3rd day: 99217

    I hope this must be helpful. I would appreciate if any other views...

    Thanks & Regards

    Pamalar CPC

  4. #4


    That's how I understand it, too.

    Quick question......Observation care requires higher levels of the key components. If the levels of the key components are not met, what would one bill? Regular outpatient? We're also taking a look at the nature of the presenting problem to see if it can be used to support the observation care.
    Sherry Miller, MBA/HCM, CPC, CEMC
    Epic Management, LP

  5. #5
    Join Date
    Apr 2007


    Here is from CPT Assistant that says for the second if not the discharge date to use 99499

    Patients in Observation Care for More Than Two Dates

    Currently, there are no instructions given in the CPT codebook on how to code hospital observation services provided on more than two dates (ie, a patient is admitted to observation status at 8:00 PM on March 1, continues to be observed on March 2, and is discharged from observation status on March 3 at 1:00 PM.

    In this example, the services provided on March 2 are coded by reporting unlisted E/M service code 99499. Also, a written report that describes the services provided on March 2 should be submitted to third-party payers when this type of service is provided.

    The CPT Editorial Panel will continue to review the types of patients requiring more than two days of observation status to determine if an additional code or codes are necessary for subsequent hospital observation services. Physicians should check with their local third-party payers for their specific reporting requirements.

  6. #6


    Thank you all for your timely responses. It's great to know you're out there.

    Thanks again


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