CPT Code Description
99224 Subsequent observation care, per day,
for the evaluation and management of a patient, which requires at least 2
of these 3 key components: Problem focused interval history; Problem
focused examination; Medical decision making that is straightforward or
of low complexity. Counseling and/or coordination of care with other
physicians, other qualified healthcare professionals, or agencies are
provided consistent with the nature of the problem(s) and the patient’s
and/or family’s needs. Usually, the patient is stable, recovering, or
improving. Typically 15 minutes are spent at the bedside and on the
patient’s hospital floor or unit.
99225 Subsequent observation
care, per day, for the evaluation and management of a patient, which
requires at least 2 of these 3 key components: An expanded problem
focused interval history; An expanded problem focused examination;
Medical decision making of moderate complexity. Counseling and/or
coordination of care with other physicians, other qualified healthcare
professionals or agencies are provided consistent with the nature of the
problem(s) and the patient’s and/or family’s needs. Usually, the
patient is responding inadequately to therapy or has developed a minor
complication. Typically 25 minutes are spent at the bedside and on the
patient’s hospital floor or unit.
99226 Subsequent observation
care, per day, for the evaluation and management of a patient, which
requires at least 2 of these 3 key components: A detailed interval
history; A detailed examination; Medical decision making of high
complexity. Counseling and/or coordination of care with other
physicians, other qualified healthcare professionals or agencies are
provided consistent with the nature of the problem(s) and the patient’s
and/or family’s needs. Usually, the patient is unstable or has developed
a significant complication or a significant new problem. Typically 35
minutes are spent at the bedside and on the patient’s hospital floor or
unit.
99234 Observation or inpatient hospital care, for the
evaluation and management of a patient including admission and
discharge on the same date which requires these 3 key components: A
detailed or comprehensive history; A detailed or comprehensive
examination; and Medical decision making that is straightforward or of
low complexity. Counseling and/or coordination of care with other
physicians, other qualified healthcare professionals or agencies are
provided consistent with the nature of the problem(s) and the patient’s
and/or family’s needs. Usually the presenting problem(s) requiring
admission are of low severity. Typically, 40 minutes are spent at the
bedside and on the patient’s hospital floor or unit.
99235
Observation or inpatient hospital care, for the evaluation and
management of a patient including admission and discharge on the same
date which requires these 3 key components: A comprehensive history; A
comprehensive examination; and Medical decision making of moderate
complexity. Counseling and/or coordination of care with other
physicians, other qualified healthcare professionals or agencies are
provided consistent with the nature of the problem(s) and the patient’s
and/or family’s needs. Usually the presenting problem(s) requiring
admission are of moderate severity. Typically, 50 minutes are spent at
the bedside and on the patient’s hospital floor or unit.
99236
Observation or inpatient hospital care, for the evaluation and
management of a patient including admission and discharge on the same
date which requires these 3 key components: A comprehensive history; A
comprehensive examination; and Medical decision making of high
complexity. Counseling and/or coordination of care with other
physicians, other qualified healthcare professionals or agencies are
provided consistent with the nature of the problem(s) and the patient’s
and/or family’s needs. Usually the presenting problem(s) requiring
admission are of high severity. Typically, 55 minutes are spent at the
bedside and on the patient’s hospital floor or unit.
Subsequent Observation Care
In
the instance that a patient is held in observation status for more than
two calendar dates, the supervising physician should utilize a
subsequent Observation Care CPT code (99224-99226). Physicians other
than the supervising physician providing care to a patient designated as
“observation status” should report subsequent Observation Care.
According to the CPT codebook, “All levels of subsequent Observation
Care include reviewing the medical record and reviewing the results of
diagnostic studies and changes in the patient’s status (i.e., changes in
history, physical conditions, and response to management) since the
last assessment.”
Observation Care Discharge Services
Per
CPT, Observation Care discharge day management CPT code 99217 “includes
final examination of the patient, discussion of the hospital stay,
instructions for continuing care and preparation of discharge records.”
Observation Care discharge services include all E/M services on the date
of discharge from observation services and should only be reported if
the discharge from observation status is on a date other than the date
of initial Observation Care.
Oxford follows CMS guidelines that
physicians should not report an Observation Care discharge Service when
theObservation Care is a minimum of 8 hours and less than 24 hours and
the patient is discharged on the same calendar date.
Observation
Care Admission and Discharge Services on Same Date Physicians who admit a
patient to Observation Care for a minimum of 8 hours, but less than 24
hours and subsequently discharge on the same calendar date shall report
an Observation or Inpatient Care Service (Including Admission and
Discharge Services) CPT code (99234-99236).
In accordance with
CMS’ Claims Processing Manual, when reporting an Observation Care
admission and discharge service CPT code (99234-99236) the medical
record must include:
** Documentation meeting the E/M requirements for history, examination and medical decision making;
Question and answers
Q:
What code should be reported for a patient who continues to be in
observation status for a second date and has not been discharged?
A: A
subsequent Observation Care CPT code (99224-99226) should be reported
in the instance a patient is held in observation status for more than 2
calendar dates. When observation discharge services are provided to the
patient, report CPT code 99217 on that calendar date. For example,
report CPT 99218- 99220 for a patient designated as observation on Day
1, report CPT 99224-99226 on Day 2 and finally report CPT 99217 when the
patient receives discharge services on Day 3.
Q: Why are Observation Codes G0378 and G0379 not addressed in this policy ?
A:
These HCPCS codes are not to be reported for physician services. These
codes are to be billed by facilities on a UB-04 claim form.
Emergency
department visits will be denied when billed on the same day as an
observation service (procedure codes 1-99217, 1-99218, 1-99219, and
1-99220) by the same provider.
Observation Care Admission and
Discharge Services on Same DatePhysicians who admit a patient to
Observation Care for a minimum of 8 hours, but less than 24 hours and
subsequently discharge on the same calendar date shall report an
Observation or Inpatient Care Service (Including Admission and Discharge
Services) CPT code (99234-99236). In accordance with CMS’ Claims
Processing Manual, when reporting an Observation Care admission and
discharge service CPT code (99234-99236) the medical record must
include:
•documentation meeting the E/M requirements for history, examination and medical decision making;
•documentation stating the stay for hospital treatment or Observation Care status involves 8 hours but less than 24 hours;
•documentation identifying the billing physician was present and personally performed the services; and
•documentationidentifying that the admission and discharge notes were written by the billing physician
Reimbursement Guidelines from Aetna Medicaid
The
order for observation must be in writing and clearly specify outpatient
observation. It should also include the reason for observation and be
signed, dated, and timed by the ordering physician. Verbal orders are
permitted but must be documented by the individual receiving the order.
The ordering practitioner must review and confirm the verbal order when
they see the patient.
Applicable Codes/Conditions of Coverage
CPT
Codes: 99218-99220, 99224 – 99226 Revenue Code 0762 These codes are not
all inclusive. For more reference please check LDH Fee Schedule. On
the rare occasion when a patient remains in observation care for 3
days, the physician shall report an initial observation care code
(99218-99220) for the first day of observation care, a subsequent
observation care code (99224-99226) for the second day of observation
care, and an observation care discharge CPT code 99217 for the
observation care on the discharge date.
Observation: Multiple Day Codes (Admitted and Discharged on Different Calendar Days)
Day 1-The First Day
There are three codes for reporting the first day of observation when the discharge is on a subsequent day:
• 99218 Low complexity
• 99219 Moderate complexity
• 99220 High complexity
The Middle Days
There are three codes for reporting the middle days of observation for observation stays greater than two days:
• 99224 Low complexity
• 99225 Moderate complexity
• 99226 High complexity
The Discharge Day
There is one code for reporting the last day of observation when the discharge is on a subsequent day:
• 99217 Observation care discharge day
This
code is used for the management of care on the final day, and is used
in conjunction with the first day series CPT codes 99218-99220 and if
applicable the middle day codes 99224-99226
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