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Observation or Inpatient Hospital Care (GEN)
Posted October 29, 2007
The Medical Review Department recently conducted a service-specific review (SSR) of observation or inpatient hospital care services (99234-99236) billed by physicians of specialty 06 (Cardiology), 08 (Family Practice), 11 (Internal Medicine), 38 (Geriatrics), 22 (Pathology), 93 (Emergency Medicine), and 97 (Physician Assistant). A complete description of these codes may be found in the Current Procedural Terminology (CPT) Manual.
This SSR (initiated in March 2007 and completed in October 2007) involved review of 100 claims (for dates of service October 1, 2006 - January 31, 2007) chosen at random by our computer system. Medicare contractors conduct these reviews to identify widespread problems by monitoring usage of procedure codes among the provider community.
On completion of SSRs, a provider error rate is calculated. An explanation of how error rates are calculated may be accessed in Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.11.1.5.
The SSR resulted in an overall error rate of 82 percent, with a down-coded/denial change rate of 84 percent. Below is a summary of the major issues and billing problems that were identified:
- Documentation did not support the criteria for observation.
- The documentation did not support a same day admission/discharge to/from observation or inpatient hospital care.
- Provider's handwriting was difficult to read or illegible.
- Higher levels of evaluation and management (E/M) services were billed to Medicare than documentation supported.
- Non-qualifying rendering providers were billing services to Medicare under another provider's number.
- Documentation did not meet the required components that would allow for an E/M service to be billed.
- Incorrect place of service (POS) 21 (inpatient hospital) was reported, as observation services are considered to be a POS 22 (outpatient hospital) service.
- Wrong rendering provider.
Per the CPT, under Evaluation and Management (E/M) Services Guidelines, Hospital Observation Services:
- 99234-99236 (observation or inpatient care) are used to "report observation or inpatient hospital care services to patients admitted and discharged on the same date of service."
These services should be used for "patients admitted to observation or inpatient care and discharged on a different date."
- 99221-99223 (initial hospital care) should be used "when a patient is admitted to the hospital from observation status on the same date." The admitting physician should include the services related to the observation status he/she provided on the same date of inpatient admission.
- 99218-99220 (initial observation care) and 99217 (observation care discharge).
- 99221-99223 (initial hospital care) and 99238/99239 (hospital discharge day management).
Per Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, §290.1, "Observation services are covered only when provided by the order of a physician or another individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient services." "Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation status is commonly assigned to patients who present to the emergency department and who then require a significant period of treatment or monitoring before a decision is made concerning their admission or discharge."
Per §290.2.2, "Observation time begins at the clock time documented in the patient's medical record, which coincides with the time the patient is placed in a bed for the purpose of initiating observation care in accordance with a physician's order." "Observation time ends when the patient is actually discharged from the hospital or admitted as an inpatient."
When billing Medicare for services rendered, providers are to follow Medicare guidelines which can be accessed on the CMS Web site at www.cms.hhs.gov/Manuals. |
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