In 2023 Observation Codesare billed with 99221-99223 and 99231 and 99233 pos 22. Are these ONLY used for the admitting phys to ObS care? What if there are other physician providing care during this timeframe, do they bill SAME codes or 99242-99245, 99202-99215, 99212-99215?
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Resolved 2023 Observation Codes
- Thread starter MaryB_77713
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Lori
Well-known member
Hospital Inpatient and
Observation Care Services
To report
initial observation care, new or established patient, see
99221,99222, 99223)
►The following codes are used to report initial and
subsequent evaluation and management services provided
to hospital inpatients and to patients designated as
hospital outpatient "observation status." Hospital
inpatient or observation care codes are also used to report
partial hospitalization services.
For patients designated/admitted as "observation status"
in a hospital, it is not necessary that the patient be located
in an observation area designated by the hospital. If such
an area does exist in a hospital (as a separate unit in the
hospital, in the emergency department, etc), these codes
may be utilized if the patient is placed in such an area.
For a patient admitted and discharged from hospital
inpatient or observation status on the same date, report
99234, 99235, 99236, as appropriate.
Total time on the date of the encounter is by calendar
date. When using MDM or total time for code selection,
a continuous service that spans the transition of two
calendar dates is a single service and is reported on one
calendar date. If the service is continuous before and
through midnight, all the time may be applied to the
reported date of the service.
New or Established Patient
►The following codes are used to report the first hospital
inpatient or observation status encounter with the
patient.
An initial service may be reported when the patient has
not received any professional services from the physician
or other qualified health care professional or another
physician or other qualified health care professional of the
exact same specialty and subspecialty who belongs to the
same group practice during the stay. When advanced
practice nurses and physician assistants are working with
physicians, they are considered as working in the exact
same specialty and subspecialty as the physician.4
For admission services for the neonate (28 days of age or
younger) requiring intensive observation, frequent
interventions, and other intensive care services, see
99477.
►When the patient is admitted to the hospital as an
inpatient or to observation status in the course of an
encounter in another site of service (eg, hospital
emergency department, office, nursing facility), the
services in the initial site may be separately reported.
Modifier 25 may be added to the other evaluation and
management service to indicate a significant, separately
identifiable service by the same physician or other
qualified health care professional was performed on the
same date.
In the case when the services in a separate site are
reported and the initial inpatient or observation care
service is a consultation service, do not report 99221,
99222, 99223, 99252, 99253, 99254, 99255. The
consultant reports the subsequent hospital inpatient or
observation care codes 99231, 99232, 99233 for the
second service on the same date.
If a consultation is performed in anticipation of, or
related to, an admission by another physician or other
qualified health care professional, and then the same
consultant performs an encounter once the patient is
admitted by the other physician or other qualified health
care professional, report the consultant's inpatient
encounter with the appropriate subsequent care code
(99231, 99232, 99233). This instruction applies whether
the consultation occurred on the date of the admission or
a date previous to the admission. It also applies for
consultations reported with any appropriate code (eg,
office or other outpatient visit or office or other
outpatient consultation).
For a patient admitted and discharged from hospital
inpatient or observation status on the same date, report
99234, 99235, 99236, as appropriate.
For the purpose of reporting an initial hospital inpatient
or observation care service, a transition ftom observation
level to inpatient does not constitute a new stay.
Consultations 99242-99245
►A consultation is a type of evaluation and management
service provided at the request of another physician, other
qualified health care professional, or appropriate source to
recommend care for a specific condition or problem.
A physician or other qualified health care professional
consultant may initiate diagnostic and/or therapeutic
services at the same or subsequent visit.
A "consultation" initiated by a patient and/or family, and
not requested by a physician, other qualified health care
professional, or other appropriate source (eg, non-clinical
social worker, educator, lawyer, or insurance company), is
not reported using the consultation codes.
The consultant's opinion and any services that were
ordered or performed must also be communicated by
written report to the requesting physician, other qualified
health care professional, or other appropriate source.
If a consultation is mandated (eg, by a third-party payer)
modifier 32 should also be reported.
►To report services when a patient is admitted to hospital
inpatient, or observation status, or to a nursing facility in
the course of an encounter in another setting, see Initial
Hospital Inpatient or Observation Care or Initial
Nursing Facility Care.
Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under Medicare regulations.
During the transitional years, 2022 and 2023, except for critical care visits*, the substantive portion can be one of the three key E/M visit components (history, exam, or medical decision-making [MDM]), or more than half of the total time spent by the physician and NPP performing the split or shared visit. In other words, for calendar year 2022 and 2023, the practitioner who spends more than half of the total time, or performs the history, exam, or MDM can be considered to have performed the substantive portion and can bill for the split or shared E/M visit.
When one of the three key components is used as the substantive portion in 2022 and 2023, the practitioner who bills the visit must perform that component in its entirety to bill.
*For critical care visits, starting for services furnished in CY 2022, the substantive portion will be more than half of the total time.
Preparing to see the patient (for example, review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically appropriate examination and/or evaluation
Counseling and educating the patient/family/caregiver
Ordering medications, tests, or procedures
Referring and communicating with other health care professionals (when not separately reported)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
Care coordination (not separately reported)
Practitioners cannot count time spent on the following:
The performance of other services that are reported separately
Travel
Teaching that is general and not limited to discussion that is required for the management of a specific patient
For all split or shared visits, one of the practitioners must have a face-to-face (in-person) contact with the patient, but it does not necessarily have to be the physician nor the practitioner who performs the substantive portion and bills for the visit. The substantive portion can be entirely with or without direct patient contact, and is determined by the proportion of total time, not whether the time involves patient contact.
Observation Care Services
To report
initial observation care, new or established patient, see
99221,99222, 99223)
►The following codes are used to report initial and
subsequent evaluation and management services provided
to hospital inpatients and to patients designated as
hospital outpatient "observation status." Hospital
inpatient or observation care codes are also used to report
partial hospitalization services.
For patients designated/admitted as "observation status"
in a hospital, it is not necessary that the patient be located
in an observation area designated by the hospital. If such
an area does exist in a hospital (as a separate unit in the
hospital, in the emergency department, etc), these codes
may be utilized if the patient is placed in such an area.
For a patient admitted and discharged from hospital
inpatient or observation status on the same date, report
99234, 99235, 99236, as appropriate.
Total time on the date of the encounter is by calendar
date. When using MDM or total time for code selection,
a continuous service that spans the transition of two
calendar dates is a single service and is reported on one
calendar date. If the service is continuous before and
through midnight, all the time may be applied to the
reported date of the service.
New or Established Patient
►The following codes are used to report the first hospital
inpatient or observation status encounter with the
patient.
An initial service may be reported when the patient has
not received any professional services from the physician
or other qualified health care professional or another
physician or other qualified health care professional of the
exact same specialty and subspecialty who belongs to the
same group practice during the stay. When advanced
practice nurses and physician assistants are working with
physicians, they are considered as working in the exact
same specialty and subspecialty as the physician.4
For admission services for the neonate (28 days of age or
younger) requiring intensive observation, frequent
interventions, and other intensive care services, see
99477.
►When the patient is admitted to the hospital as an
inpatient or to observation status in the course of an
encounter in another site of service (eg, hospital
emergency department, office, nursing facility), the
services in the initial site may be separately reported.
Modifier 25 may be added to the other evaluation and
management service to indicate a significant, separately
identifiable service by the same physician or other
qualified health care professional was performed on the
same date.
In the case when the services in a separate site are
reported and the initial inpatient or observation care
service is a consultation service, do not report 99221,
99222, 99223, 99252, 99253, 99254, 99255. The
consultant reports the subsequent hospital inpatient or
observation care codes 99231, 99232, 99233 for the
second service on the same date.
If a consultation is performed in anticipation of, or
related to, an admission by another physician or other
qualified health care professional, and then the same
consultant performs an encounter once the patient is
admitted by the other physician or other qualified health
care professional, report the consultant's inpatient
encounter with the appropriate subsequent care code
(99231, 99232, 99233). This instruction applies whether
the consultation occurred on the date of the admission or
a date previous to the admission. It also applies for
consultations reported with any appropriate code (eg,
office or other outpatient visit or office or other
outpatient consultation).
For a patient admitted and discharged from hospital
inpatient or observation status on the same date, report
99234, 99235, 99236, as appropriate.
For the purpose of reporting an initial hospital inpatient
or observation care service, a transition ftom observation
level to inpatient does not constitute a new stay.
Consultations 99242-99245
►A consultation is a type of evaluation and management
service provided at the request of another physician, other
qualified health care professional, or appropriate source to
recommend care for a specific condition or problem.
A physician or other qualified health care professional
consultant may initiate diagnostic and/or therapeutic
services at the same or subsequent visit.
A "consultation" initiated by a patient and/or family, and
not requested by a physician, other qualified health care
professional, or other appropriate source (eg, non-clinical
social worker, educator, lawyer, or insurance company), is
not reported using the consultation codes.
The consultant's opinion and any services that were
ordered or performed must also be communicated by
written report to the requesting physician, other qualified
health care professional, or other appropriate source.
If a consultation is mandated (eg, by a third-party payer)
modifier 32 should also be reported.
►To report services when a patient is admitted to hospital
inpatient, or observation status, or to a nursing facility in
the course of an encounter in another setting, see Initial
Hospital Inpatient or Observation Care or Initial
Nursing Facility Care.
Split or shared E/M guidelines
On January 1 new Medicare evaluation and management (E/M) guidelines are now in effect regarding split or shared services. The CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 30.6.18 includes a detailed breakdown of the new split or shared guidelines. This article summarizes the new Medicare E/M guidelines for split or shared E/M services effective in 2022.Definition of split or shared visit
A split or shared visit is an E/M visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit.Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under Medicare regulations.
Definition of substantive portion
Beginning January 1, 2024, substantive portion means more than half of the total time spent by the physician and NPP performing the split or shared visit.During the transitional years, 2022 and 2023, except for critical care visits*, the substantive portion can be one of the three key E/M visit components (history, exam, or medical decision-making [MDM]), or more than half of the total time spent by the physician and NPP performing the split or shared visit. In other words, for calendar year 2022 and 2023, the practitioner who spends more than half of the total time, or performs the history, exam, or MDM can be considered to have performed the substantive portion and can bill for the split or shared E/M visit.
When one of the three key components is used as the substantive portion in 2022 and 2023, the practitioner who bills the visit must perform that component in its entirety to bill.
*For critical care visits, starting for services furnished in CY 2022, the substantive portion will be more than half of the total time.
Distinct time
When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted.Qualifying time
Drawing on the CPT E/M guidelines, except for critical care visits, the following listing of activities can be counted toward total time for purposes of determining the substantive portion, when performed and whether or not the activities involve direct patient contact:Preparing to see the patient (for example, review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically appropriate examination and/or evaluation
Counseling and educating the patient/family/caregiver
Ordering medications, tests, or procedures
Referring and communicating with other health care professionals (when not separately reported)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
Care coordination (not separately reported)
Practitioners cannot count time spent on the following:
The performance of other services that are reported separately
Travel
Teaching that is general and not limited to discussion that is required for the management of a specific patient
For all split or shared visits, one of the practitioners must have a face-to-face (in-person) contact with the patient, but it does not necessarily have to be the physician nor the practitioner who performs the substantive portion and bills for the visit. The substantive portion can be entirely with or without direct patient contact, and is determined by the proportion of total time, not whether the time involves patient contact.
- Status