Subsequent Observation Care

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Posts: 11
Joined: Wed May 11, 2016 8:54 pm

Wed Feb 14, 2018 1:00 pm

Chapter 12, Section 30.6.8.A of the Medicare Claims Processing Manual indicates that the Centers for Medicare & Medicaid Services (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.

Can a provider bill for subsequent observation services if they did not order it?
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Thu Feb 15, 2018 9:09 am

Good Morning-

The provider who did not place the order for observation will bill the outpatient codes for the initial day they see them and the subsequent days if care continues. For the initial DOS they see the patient they would code new (99201-99205) or established E/M (99211-99215) depending on whether or not that patient is established with them or their practice. The subsequent DOS would then be coded as an established E/M code 99211-99215.

This is an explanation from CMS:
For patients receiving hospital outpatient observation services who are not subsequently admitted to the hospital as inpatients, physicians should report CPT codes 99217-99220. In the event another physician evaluation is necessary, the physician who provides the additional evaluation bills the office or other outpatient visit codes when they provide services to the patient.
• For example, if an internist orders observation services, furnishes the initial evaluation, 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 patient office or other outpatient visit codes as appropriate. ... mm6740.pdf

Your question has been answered by Stephanie Allard, CPC, CEMA, RHIT
Posts: 11
Joined: Wed May 11, 2016 8:54 pm

Sun Feb 18, 2018 9:54 pm

I finally found something and luckily it is from our MAC, WPS. Sorry, I did look first but since they merged with GHA their web site has become,.. 'difficult'. In fact, I suggest we note that in their chart. Seinfeld! :D

This seems to indicate that our hospitalists do not have to be the one that ordered observation to bill subsequent observation care.

Initial Observation Care 99218 – 99220
The physician ordering the observation care and ordering services to determine whether the patient should be admitted to an inpatient status or discharged, may submit the initial observation codes. The initial observation is available on the date the patient started observation care. Any other physician seeing the patient would submit the office or other outpatient care services.

Subsequent Observation Care 99224 – 99226
The treating/supervising physician may submit the subsequent observation care procedure codes. This treating/supervising physician is the single physician providing observation care on that date of service. This physician does not have to be the same as the ordering physician, nor must they be in the same group with the same specialty.

On a side note,.... this doesn't make sense to me. Only the ordering phys can bill observation on the initial day, but not subsequent? I can understand that only one provider can bill it but in our case, no one is billing initial observation care. I know we need to fix the root cause (the ED phys ordering it) but we have several charts that are complete with patients discharged that need to be billed.
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