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Outpatient vs Observation

  1. #1
    Default Outpatient vs Observation
    Medical Coding Books
    Dr. has a patient had a stress test here in our office, it is abnormal, scheduled a Cath in the hospital, patient shows up at the hospital for the Cath, Doc does and H & P on the patient after the Cath because the patient is going to spend the night, patient had to get a stent that same day by another doc in our practice. Now here is where it gets sticky:

    Hospital has patient listed as Outpatient, then also listed as Outpatient in Bed

    I say bill 99218-25, 93458 11/17/11
    99217 11/18/11

    He coded as 99214-25 no bed,93458 11/17/11
    99214 11/18/11

    Of all the seminars and webinars and such that I have been to, I've been led to believe that Outpatient and Observation is pretty much the same thing.

    Please Help!!!!

  2. #2
    Gainesville, Florida
    Hi Everyone, I am wondering if someone can help me out. I am trying to find an answer as to if you can bill and E & M and 96372 on the same day to an insurance companies and get paid for both?

  3. #3
    RKN122306: Sounds like observation to me - you'll get a denial for using an outpatient office visit code with an inpatient POS. Will the patient have to be discharged? And if so, is it on the same DOS, or on a subsequent day? If a discharge is done, then it's definitely observation status; the # of days involved will tell you which observation codes to use.

    chwilliams: Yes, you can bill both, as long as you have a 25 modifier on the E/M. You can't bill 96372 w/99211, though, because 99211 doesn't meet the criteria to be considered a 'significant/separately identifiable' E/M service.

    Hope that helps!

  4. #4
    Thanks for the input, but the hospital has it as Outpatient so the POS would be OP, got that part of it, what do you think of the no bed situation? Thats my biggest concern.

  5. #5
    Quote Originally Posted by RKN122306 View Post
    Thanks for the input, but the hospital has it as Outpatient so the POS would be OP, got that part of it, what do you think of the no bed situation? Thats my biggest concern.
    Read over the guidelines on page 13 of the CPT - it may give you comfort...notice that there's no mention of a bed requirement, or even a specific area of the hospital. If they're being formally observed, I'd use the observation code. I'd only use a 9921X code, if the patient came in for a visit, and left after it was over. Does that make sense?

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