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observation codes

SuperCoder Posted Tue 01st of February, 2011 19:36:35 PM

what code do you use when your Gastroenterologist sees a patient in the hospital, does a procedure and then follows up. Apparently the hospital billed this as out patient so this patient must have been on an "observation status".

SuperCoder Answered Tue 01st of February, 2011 20:19:01 PM

Medicare Claims Processing Manual, section 30.6.8 offers helpful insights. If this was truly observation (and there should be documentation of that), then you need to look at who admitted the patient to observation to determine the code. Here's an excerpt from 30.6.8:

"Payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient’s observation services began. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.

"For example, if an internist orders observation services and asks another physician to additionally evaluate the patient, only the internist may bill the initial observation care code. The other physician who evaluates the patient must bill the new or established office or other outpatient visit codes as appropriate."

That same section offers examples of decision for surgery during observation, such as this one for major surgery:

"An emergency department physician orders hospital outpatient observation services for a patient with a head injury. A neurosurgeon is called in to evaluate the need for surgery while the patient is receiving observation services and decides that the patient requires surgery. The surgeon would bill a new or established office or other outpatient visit code as appropriate with the “-57” modifier to indicate that the decision for surgery was made during the evaluation. The surgeon must bill the office or other outpatient visit code because the patient receiving hospital outpatient observation services is not an inpatient of the hospital. Only the physician who ordered hospital outpatient observation services may bill for initial observation care."


SuperCoder Posted Wed 02nd of February, 2011 16:33:53 PM

Thanks Deborah but can you help me decide which observation code to use. That is what I am not sure. Do I use the 99211 series or 99234 series or 99231 series and use place of service out patient. I really apprecaite your help.

SuperCoder Answered Thu 03rd of February, 2011 16:40:28 PM

Plrease refer to:

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