New Observation Care Codes for Family Practice


Keep These Rules in mind while using the new observation care codes

Some medical billing and coding rules to remember when using the new subsequent observation care codes, do not report an office visit, ED visit, initial hosp observation care or observation care discharge on the same date of service as subsequent observation care.

Observation care codes are timed based codes. So you may use prolonged services in addition to observation care codes. A tricky thing though, although observation care codes are outpatient codes for counting time, you follow inpatient time counting rules and count unit floor time.

Use a subsequent care code on a different date after first using an initial observation care code. Although that may seem logical, there are many questions raised about when you would use these codes and the order. So let's go over a medical billing and coding example.

A 60 year old female, patient with nausea, vomiting and crampy abdominal pain presents to the ED. The patient is evaluated and admitted to observation status. The attending physician, a family physician does not feel the patient can be discharged that date. The surgical consult is requested and the surgeon provides consultation services.

In this case, the family physician reports 99219 for the initial observation care. And the surgeon reports 99244 for the office consultations since this is a non-Medicare patient whose insurer allows consultation code.

The next morning, the FP finds that the patient is responding to therapy. Although the patient’s condition has improved, the FP is concerned with the patient’s hydration levels and then decides to continue observation. The surgeon also sees the patient on the same day. For CPT codes guidelines, both physicians will report 99255 for the subsequent observation care.

Then on the next day, the family physician discharges the patient and reports 99217 for observation care discharge services. When the initiating provider request another provider’s opinion on a Medicare beneficiary, should you use this new subsequent observation care codes rather than an office visit code?

Peter Hollmann presented at the AMA Symposium of the E M codes raised the same question. His answer however was open-ended that it depends on Medicare’s consultation code rules which spilled aside at the beginning of the year.

The CMS medical directors did not respond to the inquiry or address the issue in their presentation. And the final rule has not answered the issue either.

There's a lot of fine green print on time in your E/M CPT 2011 manual. All the print boils down to basically one thing – you can round to the closest time code. But that advice from CPT contradicts Medicare’s threshold time guideline.

CPT 2011 indicates you can use the code closest to the documented time. And that advice is nothing new. In selecting time, the physician must have spent time closest to code selected, states CPT Assistant back in August of 2004.

Your documented time is equal or exceeds the average time unit to bill that level. For the 35 minute spent, is it spent on the medical necessary counseling dominated visit, you can report 99214 according to CMS. But per CPT, you could actually report 99215.

The Medicare has always considered times indicated in CPT’s code descriptors to represent minimums. The physician would select a lower code for instance with the 99214 which has physicians typically spend 25 minutes face to face with the patient and/or family. Unless the time was greater than or equal to that codes require time, you would report that code until you met the threshold for the next code.

CPT however, allows you to report the next code when you pass the halfway point. So for 99213, you can actually have services that go from 12.6 minutes to 20.5, all falling under 99213 and start reporting 99214 at 20.6 minutes.

At the CPT and RBRVS Symposium, one questioned on whether Medicare would change the allotment from threshold to averages. Medical directors were reluctant to give an answer. “I don’t want to say one way either yes or no at this time” said EMX for Debra, MD, Clinical Medical Director for Trailblazer Health Enterprises.

Medical Billing and Coding Tip: One more time rule to remember, when clearly sometimes count only that calendar days minutes toward a service. If you have discontinued a service such as infusion therapy on one calendar day and then begun the infusion or time based code on the second day, you're going to tally the minutes for each day and report that initial service on the second day.

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