Observation and Discharge Policy, Professional - UnitedHealthcare Commercial Plans

Overview

Initial Observation Care CPT® codes 99218-99220 and Subsequent Observation Care CPT codes 99224-99226 are used to report evaluation and management (E/M) services provided to new or established patients designated as "observation status" in a hospital.

Observation Care Discharge Day Management CPT Code 99217 is used to report all services provided to a patient discharged from outpatient hospital “observation status” if the discharge is on a date other than the initial date of  “observation status”.

Observation or Inpatient Hospital Care (including admission and discharge) CPT codes 99234-99236 are used to report observation or initial hospital services for a patient that is admitted and discharged on the same date of service.

Inpatient Hospital Discharge Day Management CPT Codes 99238 and 99239 are used to report all discharge day management services for the hospital inpatient when discharge is on a date other than the initial date of admission.

Policy Codes

Find your specific codes below.

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  • 99217
  • 99218
  • 99219
  • 99220
  • 99224
  • 99225
  • 99226
  • 99234
  • 99235
  • 99236
  • 99238
  • 99239
* COMM-Observation-Care-Evaluation-Mgmt-Codes-Policy.pdf
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Questions & Answers

Q: Can Observation Care code 99217 and codes 99218-99220 be reported on the same date of service? 

A: No. CPT codes 99234 - 99236 should be reported for patients who are admitted to and discharged from observation status on the same calendar date for a minimum of 8 hours, but less than 24.  An initial Observation Care CPT code (99218 - 99220) should be reported for patients admitted and discharged from observation status for less than 8 hours on a calendar date.  CPT code 99217 can only be reported for a patient discharged on a different calendar date.

Q: Does the patient need to be in an observation unit in order to report the Observation Care codes? 

A: It is not necessary that the patient be located in an observation area, designated by the hospital, as long as the medical record indicates that the patient was admitted to “observation status” and the reason for the admission to “observation status” is documented in the patient’s medical record.

Q: What code should be reported for services provided by the Admitting/Supervising Physician or Other Qualified Health Care Professional for a patient who continues to be in observation status for a second calendar date and has not been discharged? 

A: A Subsequent Observation Care CPT code (99224-99226) should be reported in the instance a patient is held in observation status for more than 2 calendar dates. When observation discharge services are provided to the patient, report CPT code 99217 on that calendar date.  For example, report CPT 99218-99220 for a patient designated as being in “observation status” on Day 1, report CPT 99224-99226 on Day 2 and finally report CPT 99217 when the patient receives discharge services on Day 3. 

Q: Why are Observation Codes G0378 and G0379 not addressed in this policy? 

A: These HCPCS codes are not to be reported for Physician or Other Qualified Health Care Professional services. These codes are to be billed by facilities on a UB-04 claim form.