99231
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.00
Facility
$44.09
Non-Facility
$44.09
Documentation Required
- The article states it contains billing and coding guidelines that complement LCD L34552; required claim documentation and any prior authorization rules should be obtained from LCD L34552 and payer-specific instructions.
- The attending physician's order (or authorized designee) must be documented and include the 'clock time' for initiation of the observation service, or the clock time may be recorded in nursing admission/observation unit notes describing the patient's condition and treatment.
- The observation start time must be documented as the clock time when the patient is placed in a bed to initiate observation care per a physician's order.
- The observation end time must be documented as the clock time when the patient is discharged from the hospital or admitted as an inpatient, defined as completion of all clinical or medical interventions and necessary follow-up care by hospital staff and physicians.
Key Coverage Criteria
- No specific coverage indications are provided in this article; coverage indications are defined in the referenced Local Coverage Determination (LCD L34552).
- Observation services are covered starting at the time a patient experiences a significant adverse reaction to a therapeutic service that is beyond the usual expected response and requires further monitoring to determine need for inpatient admission.
- Observation services are covered when a bed and periodic monitoring are used to evaluate an outpatient's condition to determine the need for possible inpatient admission.
- Observation services are covered only when provided under a physician's order or the order of a person authorized by state statute and the hospital's bylaws to admit patients or order outpatient testing.
- Observation services are covered to evaluate patients who present with an unstable medical condition characterized by variance from normal laboratory values and clinical signs or symptoms outside the patient's normal range that require further monitoring and potential immediate intervention.
- Observation services are covered starting at the time a patient experiences a significant adverse reaction to an invasive diagnostic test that is beyond the usual expected response and requires further monitoring to determine if inpatient admission is needed.
2 Active Policies
A56673 — Billing and Coding: Outpatient Observation Bed/Room Services
L34552 — Outpatient Observation Bed/Room Services
Related Codes
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