October 22,
2013
Drill Down –
Observation Care Admission and Discharge Same Date
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 that
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
Physician/Non-Physician Practitioner
·
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.
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