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Two Midnight Rule Physician Billing

Stacy Posted Tue 04th of February, 2014 15:47:55 PM

The patient comes to the hospital at 1:00 PM on Monday and is put in observation status by the physician. The patient stays in observation until 9:AM on Wednesday morning at which time the status is changed to inpatient and the patient is then discharged on Friday.
Question: What E&M code range does the physician choose from on Monday, Tuesday and Wednesday to bill for the physician evaluation and management service? We are being told different things.
Some tell us that once the patient’s status changes on Wednesday, we should then go back to Monday and Tuesday and bill using an inpatient code even though the patient was in observation status on Monday and Tuesday.
Thank you!

SuperCoder Answered Mon 10th of February, 2014 13:24:22 PM

CMS hosted a National Provider Call in January that clarified some issues pertinent to the 2-Midnight Rule. Some information from that call that you might find helpful includes:
- Contractors will include time the beneficiary spends as an outpatient in their review decision.
- The total time for your patient was 2 midnights (Monday and Tuesday). CMS says that if the total time the beneficiary is expected to spend receiving medically necessary hospital care (including both inpatient and outpatient care) is 2 or more midnights, then the review contractor will generally find Part A payment to be appropriate.
Based on this, I would say you can bill all the services the patient received as Part A/inpatient services. That would lead you to E/M codes 99221-99223 for initial inpatient care or 99231-99233 for subsequent hospital E/M care.

I hope this helps!

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