When CPT eliminated observation care designations from its coding lineup earlier this year, some coders were puzzled about how to report same-day admissions and discharges. Despite the coding rules being overhauled, that didn’t change the fact that patients may be 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, CPT has accommodated for that, 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
In the past, codes in the 99234-99236 range described observation or inpatient care with admission and discharge on the same date. Now, however, you’ll find new descriptors for these codes, 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.
CMS Has Its Own Rules
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. For Medicare and Medicaid patients, CMS says the patient has to be admitted for at least eight hours.
In addition, CMS indicates that the codes require documentation of two or more encounters: one should be an initial admission encounter and another a discharge encounter. If your provider dictates a summary noting that the patient was admitted and discharged on the same date, that will not be enough for Medicare payers. You must have documentation of the two (or more) separate encounters, CMS says.
Meet the Prolonged Service Thresholds
The codes in the 99234-99236 range clearly indicate the amount of time you must document to justify each code level, but if you’re planning to report a prolonged service code (typically 99418), keep in mind that CPT and CMS differ on the time thresholds you must meet.
If you’re following CPT rules, you must meet 100 minutes as the threshold to report 99418. For Medicare, however, that threshold climbs to 125 minutes.
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
The E/M coding guidelines changed dramatically this year—without help, it can be difficult to code properly. Let expert Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, help! During her 90-minute online training event, “Master New 2023 E/M Coding Changes,” Kim will walk you through the details you need to know so you can code correctly this year. Sign up today!
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