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Fam Pract Manag. 2001;8(6):14

To the Editor:

In “Answers to Your Questions” [Coding & Documentation, February 2001, page 14], the author advised physicians to use CPT code 99499, “Unlisted evaluation and management service,” to code the second day of a three-day observation stay. I recommend using codes 99212-99215 instead. The reimbursement for 99212 would be roughly equal to that for 99499, but using codes 99213, 99214 or 99215 would generate higher reimbursement. A source at the Health Care Financing Administration’s (HCFA) regional office in Dallas prompted me to start recommending this approach to my clients about seven years ago. Medicare carriers expect to see these codes used on the second day of a three-day observation stay and will even pay for three separate visits. We almost never have this questioned by any carrier.

Author’s response:

I based my advice on information from the AMA, which owns and maintains CPT. The AMA’s CPT Assistant newsletter addressed the issue in April 1996.

Mr. Self is correct that Medicare requires a different coding convention. According to section 15504.B of the Medicare Carriers Manual, “In the rare circumstance when a patient is held in observation status for more than two calendar dates, the physician must bill subsequent services furnished before the date of discharge using the outpatient/office visit codes.”

Unfortunately, we cannot guarantee that all third-party payers will agree with this or any other coding recommendation, including Mr. Self’s. The best approach for practices is always to check with their local Medicare carrier and the other payers they submit claims to. The differences between payers can be significant.



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