observation as a teaching physician

Resident sees patient in observation Monday
Teaching Physician sees patient on Tuesday
Patient is discharged from observation Tuesday
What should Teaching Physician bill for Tuesday?
initial observation (99218-99220) or discharge from observation (99217) or observation admit/discharge same date of service (99234-99236)



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    what did he document

    In a message dated 1/19/2017 3:52:18 P.M. Eastern Standard Time,
    michele.fecho@readinghealth.org writes:

    Resident sees patient in observation Monday
    Teaching Physician sees patient on Tuesday
    Patient is discharged from observation Tuesday
    What should Teaching Physician bill for Tuesday?
    initial observation (99218-99220) or discharge from observation (99217) or
    observation admit/discharge same date of service (99234-99236)


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  • I have seen/examined the patient at 9:38 AM. I have reviewed the notes/assessments documented by the resident . I concur with her/his documentation. Plan per their note, see note for additional details.

    To review some of the key points: Pt who came to the emergency room after developing cough and congestion the morning of admission. He initially went to urgent care. The doctor there was concerned about his breathing and sent him to the emergency room. he seemed improved after receiving meds in the emergency room. At the time that I saw him, he had just wakened. His mother said he slept okay during the night after got to the pediatric floor. On exam he is very cooperative and seemed in no distress. His breath sounds were coarse. No definite wheezes. His chest x-ray did not show any infiltrate but suggested bronchitis. His heart was regular without a murmur. His abdomen is soft and nontender. The admitting diagnosis was croup and a barky cough was reported earlier.. He does seem improved and if he remains stable or improves he may be able to go home later today.

  • I think note is very iffy - never says he specifically examined the
    patient - says seen/examined.

    But if you accept this, I would bill initial observation.only.

    I would have compliance look at this type of note and determine if they
    think it is suffiecient


  • Doesn't it just go under the date that coincides with the documentation of the resident. Doesn't the attending have a certain amount of time In which to sign off?

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor

  • Hello,
    I rarely respond to the list serve. However, this information might
    assist you.

    100.1.1 - Evaluation and Management (E/M) Services
    (Rev. 2303, Issued: 09-14-11, Effective: 06-01-11, Implementation:
    A. General Documentation Instructions and Common Scenarios
    When a medical resident admits a patient to a hospital late at night
    and the teaching physician does not see the patient until later,
    including the next calendar day:
    * The teaching physician must document that he/she personally saw the
    patient and participated in the management of the patient. The teaching
    physician may reference the resident's note in lieu of re-documenting
    the history of present illness, exam, medical decision-making, review of
    systems and/or past family/social history provided that the patient's
    condition has not changed, and the teaching physician agrees with the
    resident's note.
    * The teaching physician's note must reflect changes in the patient's
    condition and clinical course that require that the resident's note be
    amended with further information to address the patient*s condition and
    course at the time the patient is seen personally by the teaching
    * The teaching physician*s bill must reflect the date of service he/she
    saw the patient and his/her personal work of obtaining a history,
    performing a physical, and participating in medical decision-making
    regardless of whether the combination of the teaching physician*s and
    resident*s documentation satisfies criteria for a higher level of
    service. For payment, the composite of the teaching physician*s entry
    and the resident*s entry together must support the medical necessity of
    the billed service and the level of the service billed by the teaching

    According to our MAC (Novitas Solutions), discharge from observation on
    the same calendar day would be billed as:
    In observation for less than eight hours - Use only the appropriate
    initial code 99218-99220
    In observation for more than eight hours up to 24 hours - Use only a
    code from range 99234-99236 Observation or Inpatient Hospital Care
    Services (Including Admission and Discharge Service Same Day)

    Thank you,

    Sonja Goss, BS, CPC, COC
    Manager of Provider Compliance
    Office of Compliance
    LifeBridge Health, Inc.
    1425 Clarkview Road, Suite 100
    Baltimore, MD 21209

    (410) 601-7262 (direct)
    (410) 601-8708 (fax)
    >>> Karyn Foray 1/23/2017 4:43 PM >>>

  • The teaching physician was selecting 99217 because when he saw the pt the next day, he discharged the pt. (although he reviewed & attested correctly to the resident's note the day before)

    If I am understanding the comments correctly, others would have gone with the 99218-99220.

    And no one uses 99234-99236 for the Teaching Physician if pt was observed overnight (even though MD admits & discharges pt same day)
  • The physician needs to indicate the date he came in and saw the patient if different from the Resident and then it has to be billed under the date of the teaching physician, but it would still be initial visit as that is what s/he is attesting to.


    [cid:image001.png@01D27CB3.7C8AD830]"Somewhere, deep inside, we can all fly." (unknown author)
    Wendy A. Weisel, CPC
    Coding & Reimbursement Analyst II
    Consolidated Coding and Billing
    University of Virginia Physicians Group
    Phone (434) 220-6365
    Fax (434) 245-5399
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