When CPT eliminated observation care designations from its coding lineup in 2023, some coders were puzzled about how to report same day admit and discharge situations, and the rules have only become more confusing as the calendar turned to 2024. After all, there are always going to be situations when patients are admitted to observation (or inpatient status) and discharged on the same date of service, and if you don’t know how to code for these encounters, you could be losing money.
Fortunately, both CPT and CMS have made their stances clear on this topic, so you can continue reporting the same day admit and discharge services that your provider performs, with a few key pointers.
Look to 99234-99236 as Your Guide
Prior to 2023, codes in the 99234-99236 range described observation or inpatient care with admission and discharge on the same date. As of last year, however, the descriptors for these codes were updated as follows:
- 99234 (Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.)
- 99235 (…which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded.)
- 99236 (…which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.)
You’ll report these codes when patients are admitted and discharged on the same date, whether they’re in observation care or admitted to inpatient status.
Although the CPT codes don’t specifically say how long the patient must be in the hospital before you can report these codes, CMS does. As of 2024, Medicare patients must be admitted for at least eight hours, but less than 24 hours, to report a code from the 99234-99236 range. In addition, the admission and discharge must occur on the same calendar date.
Meet CMS’ Prolonged Service Thresholds
The codes in the 99234-99236 range clearly indicate the amount of time you must document to justify each code level, and if you’re planning to report a prolonged service code for time that exceeds 85 minutes, keep in mind that CMS and CPT dictate specific thresholds there.
Here’s how to calculate for CMS in 2024: You must meet or exceed 110 minutes to report 99236 to Medicare payers with G0316 (Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services…).
This differs from CMS’ original time threshold of 125 minutes, which the agency updated when it released Transmittal 11842. This transmittal clarifies that you can report G0316 and 99236 for extra time during same day admit and discharge services if the total documented time meets the 110-minute time threshold.
Here’s how to calculate for CPT in 2024: The rules for prolonged services when billing payers that don’t follow Medicare guidelines are slightly different. Because G0316 is a Medicare-specific code, you’ll instead turn to 99418 (Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time) for same day admit and discharge services that last 100 minutes or longer. This time threshold is printed right in your CPT manual.
Keep in mind, however, that individual insurers may have their own guidelines, so always check with your payers about their time thresholds.
Check These Examples
To ensure that you’re reporting your same-day admissions and discharges properly, check these two examples of what might meet the 99235 and 99236 code levels:
- 99235 – The patient is seen in the emergency department for chest pain. Nitroglycerin was given, but chest pain did not resolve. Cardiac enzymes were slightly elevated. Patient was admitted to observation. Nine hours later, the chest pain subsided; patient was discharged home with a diagnosis of angina.
- Number and Complexity: Moderate – undiagnosed new problem with uncertain prognosis
- Data: Moderate – 3+ diagnostic tests
- Risk: High – Decision regarding hospitalization
- 99236 – The patient was admitted for an overdose; activated charcoal was administered. The patient was admitted for observation. 10 hours later, patient has recovered and is discharged.
- Number and Complexity: High – acute or chronic illness that poses a threat to life or body function in the near term without treatment
- Risk: High – Decision regarding hospitalization
There’s so much more to know about how to code inpatient encounters properly in 2024. Let expert Dreama Sloan-Kelly, MD, CCS, CPC help! During her 60-minute online training event, Improve Inpatient Coding (99221-99239) Accuracy & Reimbursement, Dreama will provide you with expert strategies that allow you to bring in maximum allowable pay for your hospital encounters. Register today!
Editor’s note: This post was originally published in 2023 and has been updated to include the latest updates.
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