RAC Region A contractor Performant posted an automated review on October 14, 2013, for Physician/Non-Physician Practitioners regarding Observation Care Admission and Discharge Same Date. The states impacted are Connecticut and New York.
Per the audit issue description, when a patient receives observation care for a minimum of 8 hours, but less than 24 hours, and is discharged on the same calendar date, observation care services (including admission and discharge services) should be reported with CPT® code 99234, 99235, or 99236. The initial observation care or observation discharge CPT codes 99217, 99218, 99219, and 99220 should not be reported.
The issue references the Medicare Claims Processing Manual – CMS 100-04, Chapter 12, Section 30.6.8:
Observation services ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.
In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours.
The CPT code utilization is defined in this Section of the Medicare Claim Processing Manual. Since this is an automated review type, the contractor will be looking at claims data along with discharge times and dates.
RAC issues for the week of October 21 – October 25, 2013:
RAC Region A Performant
- Observation Care Admission and Discharge Same Date – JK - When a patient receives observation care for a minimum of 8 hours, but less than 24 hours, and is discharged on the same calendar date, observation care services (including admission and discharge services) should be reported with CPT code 99234, 99235 or 99236. The initial observation care or observation discharge CPT codes 99217, 99218, 99219 and 99220 should not be reported.
About the Author
Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payers.
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