ER/Observation/Inpatient Consult?

[BABS37]

I can't seem to get the E/M correct for this date of service and it keeps coming back denied denied denied. Here's what was done prior to this visit: Can anyone help with this?

01/30/2012 45380 (biopsy due to bleeding and mass of the anus)
02/06/2012 99212 (declare as neoplasm of rectum)
02/13/2012 45172 (cut out the mass)
02/17/2012 45317-78 (goes back for sigmoidoscopy as they cant get the bleeding to stop)

The patient came in to the ER on 02/17/12 at 1:00 A.M.- my physician goes in to do the consult and 'plans to admit and observe her' from the ER. At 6:00 A.M. that morning, he does a 'SOAP' progress note and sees she is still bleeding a lot so they take her back to the OR. I thought I needed to bill an ER visit initially with the AI modifier and 58- but then I went with the observation code- UHC is saying that anything else done that day- other than the sigmoidoscopy isn't billable. Is this right and if not, what code am I suppose to be billing for?

[kbarron]

What about 27 modifier for outpatient services the last service before OR

[BABS37]

So would I bill 99283-27 and what else? I tried 99283-25-AI, 99283-25-both have denied and so did 99234-58...my brain is fried over thinking this one.

[kbarron]

UHC has some pretty tight requirements. My understanding is that the 27 goes on the last outpatient code. It gives" MD means for reporting the use of hospital resources when providing multiple E&M services in multiple outpatient settings on the same date". Why are you using two E&M ER visit codes together?...

[BABS37]

Just to clarify- I didn't bill all those codes the same day- I started with 99283-AI-25 for ER visit to admitting physician. When it denied, I figured I did it wrong so I dropped the AI. When that denied, I tried to bill for just the observation instead of the ER visit.

Can the hospital bill for the observation charge- even though my doc did the ER visit and also the follow inpatient/observation visit?

[kbarron]

We have hospitalist who admit IP. Our surgeons will go to the ER and decide if surgery is needed because the ER MD has called for a "consult". (Maybe consult code is needed).(MCR does not allow consults but other ins do) If surgery is needed the a 57 modifier is used, as I am sure you are aware of. UHC is a bugger to get claims paid. Perhaps you can speak to your provider rep and let them know what your issue is. Also the patient may have a plan that does not allow what you are billing. It may be bundled. Good luck...time to go home east coast time!