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OBSERVATION OR INPATIENT CARE SERVICES – INCLUDING ADMISSION AND DISCHARGE SERVICES - CPT CODES 99234-99236 This series of codes is used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service. In order to use these codes for a Medicare patient, the patient must have been an inpatient or an observation care patient for a minimum of eight (8) hours on the same calendar date. When observation status or initial inpatient hospital care is initiated in the course of an encounter in another site of service (e.g., hospital emergency department, physician’s office, nursing facility) all evaluation and management services provided by the supervising physician in conjunction with initiating observation status are considered part of the initial observation care or initial inpatient hospital care when performed on the same date. The level of service should include the services related to the admission provided in the other sites-of-service as well as in the observation setting when provided by the same physician. Newby Note: To use codes 99234-99236, the physician must clearly indicate in the patient’s medical record the number of hours the patient was in observation or inpatient status. For patients admitted to observation or inpatient care for less than eight (8) hours or discharged on a different date, see codes 99218-99220 and 99217, or 99221-99223 and 99238-99239. INPATIENT HOSPITAL VISITS – CPT CODES 99221-99239 Medicare Claims Processing Manual Chapter 12 §30.6.9 General (Codes 99221-99239) (Rev. 1, 10-01- 03) B3-15505-15505.2 A. Hospital Visit and Critical Care on Same Day If critical care is required upon the patient’s presentation to the emergency department, only critical care codes 99291-99292 may be reported. Emergency department codes will not be paid for the same day. If there is a hospital or office/outpatient evaluation and management service furnished early in the day and at that time the patient does not require critical care, but the patient requires critical care later in the day, both critical care and the evaluation and management service may be paid. Physicians must submit supporting documentation when critical care is billed on the same day as other evaluation and management services. B. Two Hospital Visits Same Day Carriers pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase per day which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service. C. Hospital Visits Same Day But by Different Physicians In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, Carriers do not pay physician B for the second visit. The hospital visit descriptors include the phrase per day meaning care for the day. 5-30 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty. D. Visits to Patients in Swing Beds If the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply. Payment for Initial Hospital Care Services Medicare Claims Processing Manual Chapter 12 §30.6.9.1 (Codes 99221-99223) (Rev. 1, 10-01-03) A. Initial Hospital Care from Emergency Room Carriers pay for an initial hospital care service or an initial inpatient consultation if a physician sees his/her patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. B. Initial Hospital Care on Day Following Visit Carriers pay both visits if a patient is seen in the office on one date and admitted to the hospital on the next date, even if fewer than 24 hours has elapsed between the visit and the admission. C. Initial Hospital Care and Discharge on Same Day Carriers pay only the initial hospital care code when a patient is admitted as an inpatient and discharged on the same day. They do not pay the hospital discharge management code on the date of admission. Newby Note: If the patient is admitted and discharged on the same date of service and the patient has been an inpatient for eight (8) or more hours, the physician may use code 99234-99236. D. Physician Services Involving Transfer From One Hospital to Another; Transfer Within Facility to Prospective Payment System (PPS) Exempt Unit of Hospital; Transfer From One Facility to Another Separate Entity Under Same Ownership and/or Part of Same Complex; or Transfer From One Department to Another Within Single Facility Physicians may bill both the hospital discharge management code and an initial hospital care code when the discharge and admission do not occur on the same day if the transfer is between: • Different hospitals; • Different facilities under common ownership which do not have merged records; or • Between the acute care hospital and a PPS exempt unit within the same hospital when there are no merged records. In all other transfer circumstances, the physician should bill only the appropriate level of subsequent hospital care for the date of transfer. E. Initial Hospital Care Service History and Physical That Is Less Than Comprehensive When a physician performs a visit or consultation that meets the definition of a Level 5 office visit or consultation several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit or consultation that reflects 5-31 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
Page 1 and 2: PQRI MEASURE CODING AND REPORTING P
Page 3 and 4: ! The line item charge should be $0
Page 5 and 6: ICD-9: 250.00-250.93, 648.00-648.04
Page 7 and 8: _____ _____ _____ _____ _____ Beta-
Page 9 and 10: Definition: Pharmacologic Therapy:
Page 11 and 12: Definition: Characterization includ
Page 13 and 14: eport the proper CPT II Category II
Page 15 and 16: • Physicians and qualified nonphy
Page 17 and 18: preoperative medical evaluation (if
Page 19 and 20: The excision of malignant lesion co
Page 21 and 22: complex repairs (CPT codes 13100-13
Page 23 and 24: HEMORRHOIDECTOMY BY SIMPLE LIGATURE
Page 25 and 26: Medicare “Incident to Clarificati
Page 27 and 28: service or other face-to-face servi
Page 29: HOSPITAL OBSERVATION SERVICES - CPT
Page 33 and 34: documented. If the time is not docu
Page 35 and 36: Follow-Up Consultation Service Effe
Page 37 and 38: A physician (primary care or specia
Page 39 and 40: typical severity of the problem(s)
Page 41 and 42: Medicare Part B payment policy does
Page 43 and 44: HOME SERVICES - CPT CODES 99341-993
Page 45 and 46: the medical records must clearly do

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