Observation Coding Clarification

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Posts: 76
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Thu Feb 01, 2018 8:54 am

I recently read an article in the RACmonitor (12/7/2017) by Ronald Hirsch, MD, FACP, CHCQM, Physician Billing for Observation: If you Don't Order it, You Can't Bill for It. In it he stated CMS Processing Manual states CMS will “pay for initial observation care billed by only the physician who ordered hospital outpatient observation services and was responsible for the patient during his/her observation care”. Does this mean that a physician from a group practice that writes an admission order in the middle of the night must be the one who does the face-to-face visit with the patient in order to bill the observation code? And, his partners in the group can’t see the patient and charge subsequent observation codes? For example, we have a group of employed hospitalists that are basically considered the same “physician” for billing purposes. When Doctor A (from the hospitalist group) is on call and admits a patient to observation via telephone at 200 a.m., the following day Dr. B (from the same hospitalist group) is on call and goes to see the patient face-to-face for the first time and bills the initial Observation code (99218-99220). Other hospitalists in the group may see the patient during the stay and bill subsequent Observation codes (992224-99226) or discharge code (99217). Can you help clear up this conundrum?
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Tue Feb 06, 2018 9:57 am

All providers in the same group under the same specialty are considered to be the same doctor. Here is an excerpt that spells this out for us and the link it is from.

“Who Can Bill for Observation Status: Only the physician admitting the patient to outpatient observation care (or a member of the same group with the same specialty) may bill the observation CPT procedure codes. This includes the admission (99218 - 99220), subsequent observation (99224 - 99226), and discharge from observation (99217) CPT procedure codes. Anyone else seeing the patient while in observation care would bill using an office or other outpatient procedure code 99201 - 99215 as appropriate. The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.8 discusses observation care. It does not mention the new subsequent observation care codes. It does state, "All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient services must bill the appropriate outpatient service codes."”

https://downloads.cms.gov/medicare-cove ... 100111.pdf

Your question has been answered by Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA
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