99218 help please?

cmac

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The physician I work for admits patient's to observation on a regular basis. I have a situation with Medicare where a patient was admitted to obsveration on 2/25 (99219), had a 2nd day in observation on 2/26 (99218) then admitted as an inpatient on 2/27 (99222) and stayed an inpatient until 3/1. All was paid except for the 99218, 2nd day in observation. The denial code was C0-151, payment adjusted b/c the payer deems the info submitted does not support this many/frequency of services. We appealed the claim and sent medical records. They've denied our appeal for the same reason.
I've pulled an EOB where they paid for the 99218 in the exact same situation. We bill this way all the time and it's paid all the time, except this one.
We are sending medical records again, along with the copy of the EOB where they paid in a previous situation.
anyone familiar or knowledgable regarding these codes and limitations? I am having a hard time finding any info on it on the Medicare website.
thanks
 

Lisa Bledsoe

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Are you saying that the patient was discharged (99218) on 2/26 and then admitted to inpatient status (99222) on 2/27? If the patient never left the hospital on 2/26 I would code that as subsequent out patient (99212-99215). That could be the issue.
 

cfullum

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On the second day of admission 2/26 an establised outpatient visit should have billed using the CPT codes 99211-99215. For 2/27 when the patient converted to inpatient, you can only bill 99221-99223 if the physician documents another complete history and physical otherwise you would have to convert to using the inpatient subsequent visits 99231-99233 since this is the day the conversion took place. I hope this helps you.
 

cmac

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the patient was never discharged. they had 2 days in observation and then was admitted to inpatient status. so the 99218-99219 is for initial care only no second day in observation? I have never known this. Always thought you used the observation codes for observation care. Mcare has been paying us this way, except for this one instance.
does anyone know of any coding references or any info on the mcare website to support this info?
thanks for your help!
 

neha.bhatnagar

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Subsequent Observation Visit

I aggree with Rebecca's opinion.

You should use one of the E/M from CPT 99211-99215 in place of CPT 99218 for subsequent observation care.

Best of Luck .
Neha Bhatnagar, CPC, CPC-H.:)
 
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