(Medicare Claims Processing Manual)

 A surgeon orders hospital outpatient observation services for a patient with abdominal pain on the 80th day following a TURP (performed by that surgeon).  While the patient is receiving hospital outpatient observation services, the surgeon decides that the  patient requires kidney surgery.  The surgeon would bill the observation code with HCPCS modifier  -57 to indicate that the decision for surgery was made while the patient was receiving hospital outpatient observation services.  The subsequent surgical procedure would be reported with modifier  -79.   A surgeon orders hospital outpatient observation services for a patient with abdominal pain on the 20th day following a resection of the colon (performed by that surgeon).  The surgeon determines that the patient requires no further colon surgery and disch arges the patient.  The surgeon may not bill for the observation services furnished during the global period because they were related to the previous surgery.   An example of a billable hospital observation service on the same day as a procedure is when a physician repairs a laceration of the scalp in the emergency department for a patient with a head injury and then subsequently orders hospital outpatient observa tion services for that patient.  The physician would bill the observation code with a CPT modifier 25 and the procedure code.   30.6.9 - Payment for Inpatient Hospital Visits - General  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23) Starting in CY 2023, hospital inpatient and observation care by practitioners will be billed using the same CPT codes, CPT codes 99221 through 99223, 99231 through 99233, and 99238 and 99239. (CPT 99234 through 99236 are already used for billing hospital i npatient or observation care (including admission or discharge.) Where they appear, references such as hospital care, hospital E/M or hospital inpatient care services in this section apply to Hospital Inpatient or Observation Care Services codes (CPT codes 99221 -99223, 99231 -99239.)    A. Hospital Visit and Critical Care on Same Day  Hospital evaluation and management (E/M) visits may be billed the same day as critical care services in certain circumstances discussed in section 30.6.12.  Documentation must support the claims as indicated in that section.   During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 - 99233.  Both Initial Hospital Care (CPT codes 99221 -  99223) and Subsequent Hospital Care codes are per diem services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.   B. Two Hospital Visits Same Day  The time counted toward the Hospital Inpatient or Observation Care codes is per day. Per day, also referred to as date of encounter, means the calendar date. When using MDM or time for code selection, a continuous service that spans the transition of 2 calendar dates is a single service and is reported on one date, which is the date the encounter begins. If the service is continuous, before and through midnight, all the time may be applied to the reported date of the service (that is, the calendar d ate the encounter began).  A billing practitioner shall bill only one of the hospital inpatient or observation care codes for an initial visit, a subsequent visit, or inpatient or observation care (including admission and discharge), as appropriate, once per calendar date. The pract itioner selects a code that reflects all of the practitioners services provided during the date of the service. The definitions of initial visit and subsequent visit for the purposes of billing observation care using the Hospital Inpatient or Observat ion Care Services codes can be found in section 30.6.9.E.   A/B MACs (B) pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not.   Note that in some cases, practitioners may bill a prolonged code in addition to the Hospital Inpatient or Observation Care Services base code; time spent by the same practitioner on the same day for the same patient in multiple settings (or for a patient w ho transitions between outpatient and inpatient status) may be counted toward the Hospital Inpatient or Observation Care Services base code and, if applicable, a prolonged code. Refer to section 30.6.9.F.)   C. Hospital Visits Same Day But by Different Physicians   In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, A/B MACs (B) do not pay physician B for the second visit.  The hospital visit descriptors include the phrase per day meaning care for the day.   If the physicians are each responsible for a different aspect of the patients care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses.  There are circumstances where concurrent care may be billed by physicians of the same specialty.   D. Visits to Patients in Swing Beds   If the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply.  If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply.  E. Definition of Initial and Subsequent Visit   An initial service is one that occurs when the patient has not received any professional services from the physician or NPP or another physician or NPP of the same specialty who belongs to the same group practice during the stay.   A subsequent service is one that occurs when the patient has received any professional services from the physician or NPP or another physician or NPP of the same specialty who belongs to the same group practice during the stay.   F. Prolonged Hospital Inpatient or Observation Care Services   Beginning January 1, 2023, prolonged services are reported for certain hospital inpatient or observation care visits using G0316. Prolonged services can be reported when time is used to select visit level, and the total practitioner time for the highest- level visit is exceeded by 15 or more minutes for services that are medically reasonable and necessary. See Prolonged Services section below for detailed reporting instructions.  30.6.9.1 - Payment for Initial Hospital Inpatient or Observation Care Services and Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services)                                                                                     (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)   A. Initial Hospital Inpatient or Observation Care From Emergency Department   A/B MACs (B) pay for an initial hospital inpatient or observation care service if a practitioner sees a patient in the emergency department and decides to admit the person to the hospital or place the patient in observation care.  They do not pay for both E/M services.  Also, they do not pay for an emergency department visit by the same practitioner on the same date of service.  When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physicians office, nursing facility), all services provided by the practitioner in conjunction with that admission are considered part of the initial hospital inpatient or observation care when performed on the same date as the admission.  B. Initial Hospital Inpatient or Observation Care on Day Following Visit   A/B MACs (B) pay both visits if a patient is seen in the office on one date and admitted to the hospital as an inpatient or receives observation care on the next date, even if fewer than 24 hours has elapsed between the visit and the admission for hospital inpatient or placement in observation care.   C. Initial Hospital Inpatient or Observation Care and Discharge on Same Day  Both hospital inpatient and observation care coding should be billed as follows:   When the patient is admitted to inpatient hospital care or is in observation care for less than 8 hours on the same date, then Initial Hospital Inpatient or Observation Care, from CPT code range 99221 -  99223, shall be reported by the physician.  The Hospi tal Inpatient or Observation Discharge Day Management service, CPT codes 99238 or 99239, shall not be reported for this scenario.   When a patient is admitted to inpatient hospital care or is in observation care and then discharged on a different calendar date, the physician shall report an Initial Hospital Inpatient or Observation Care from CPT code range 99221 -  99223 and a Hospital Inpatient or Observation Discharge Day Management service, CPT code 99238 or 99239.  When a patient has been admitted to inpatient hospital care or is in observation care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Hospital Inpatient or Observation Care Services (Including Admission and Dischar ge Services), from CPT code range 99234 - 99236, shall be reported.   The following table summarizes the above, based on hospital length of stay and discharge date:  Hospital Length of Stay  Discharged On  Code(s) to Bill  < 8 hours  Same calendar date as admission or start of observation  Initial hospital services only* 8 or more hours  Same calendar date as admission or start of observation  Same -day admission/discharge*  < 8 hours  Different calendar date than admission or start of observation  Initial hospital services only* 8 or more hours  Different calendar date than admission or start of observation  Initial hospital services* + discharge day management  *Plus  prolonged inpatient/observation services, if applicable.    D. Documentation Requirements for Billing Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services)   The physician shall satisfy the E/M documentation guidelines for admission to and discharge from inpatient observation or hospital care.  In addition to meeting the documentation requirements for medically appropriate history and/or examination, and medica l decision making documentation in the medical record shall include:    Documentation stating the stay for hospital treatment or observation care status involves 8 hours but less than 24 hours;    Documentation identifying the billing physician was present and personally performed the services; and    Documentation identifying the admission and discharge notes were written by the billing physician.    E. Physician Services Involving Transfer From One Hospital to Another; Transfer Within Facility to Prospective Payment System (PPS) Exempt Unit of Hospital; Transfer From One Facility to Another Separate Entity Under Same Ownership and/or Part of Same Comp lex; or Transfer From One Department to Another Within Single Facility   Physicians may bill both the hospital discharge management code and an initial hospital care code when the discharge and admission do not occur on the same day if the transfer is between:    Different hospitals;   Different facilities under common ownership which do not have merged records; or    Between the acute care hospital and a PPS exempt unit within the same hospital when there are no merged records.   In all other transfer circumstances, the physician should bill only the appropriate level of subsequent hospital care for the date of transfer.   F. Initial Hospital Care Service Requirements   Per the CPT code descriptors for Initial Hospital Inpatient or Observation Care Services, a medically appropriate history and/or examination will be required, but will no longer be used to select visit level. Practitioners working in hospitals should conti nue to be aware of the documentation needed to meet requirements for other payment systems or Conditions of Participation, in addition to the documentation required to bill Hospital Inpatient or Observation Care codes under the PFS.   Physicians who provide an initial visit to a patient during inpatient hospital care that meets the code descriptor requirements shall report an initial hospital care code (99221- 99223). The principal physician of record shall append modifier  -AI (Princip al Physician of Record) to the claim for the initial hospital care code.  This modifier will identify the physician who oversees the patients care from all other physicians who may be furnishing specialty care.   Physicians may bill initial hospital care service codes (99221- 99223), for services that were reported with CPT consultation codes (99241 -  99255) prior to January 1, 2010, when the furnished service and documentation meet the Initial Hospital Inpatient or  Observation Care code descriptor requirements.  Physicians must meet all the requirements of the initial hospital care codes, to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.   Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service.  Reporting CPT code 99499 requires submission of medical records and A/B MAC (B) manual medical review of the service prior to payment.  A/B MACs (B) shall expect reporting under these circumstances to be unusual.  G. Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are Involved in Same Admission