Patient is not Inpatient or Observation Status

Today’s post covers the patient scenario where they are neither an Inpatient Hospital nor Observation status. This is also referred to as “outpatient in a bed.” In 2023, what options do we have under the AMA’s new E/M changes?

• Other Outpatient/Office CPT codes 99202-99215, or
• Outpatient Consultation CPT codes 99242-99245
  • For those carriers that still recognize consultation codes, and
  • As long as all consultation criteria has been met

This was the one area that wasn’t addressed by the AMA when they made the changes for the hospital setting.

For example:  Patient has outpatient surgery. They stay in the hospital for a few days. While they are there, a hospitalist team manages their chronic medical conditions (e.g. hypertension, hyperlipidemia, or diabetes). The patient doesn’t meet Inpatient admission criteria. There isn’t an order to admit as Observation status. The hospitalists are rounding daily.

Their code choice is between a new or established office visit code. They may use MDM or time to decide the level. Also keep in mind, shared visits may occur in the facility setting. Incident-to only applies to the “office” setting (POS 11), not just the code set. Shared visits may occur in any facility setting, but not in the clinic/office (see below).

The RacMonitor and the ICD10Monitor both have excellent articles that address these pitfalls.

For more information, please see our 2023 E/M Changes page.

If you would like to schedule training, please e-mail me at [email protected].

---