Wiki E&M in an ambulatory surgical center

[alexandasia]

Hi,

I have a vascular surgeon who has contracted with a large kidney group. They have some sort or arrangement where when the patient is ready for dialysis my doc is the one putting in the line. The kidney group has their own ASC. My doctor doesn't actually see the patient until the day they are scheduled for their access port. So he has been coding a consult and then the procedure code. 99.9% of the patients are medicare so we have had to convert his codes from consults. Not a big deal, however many insurances are denying the E&M for inappropriate code. Typically the code ends up a 99235. I can't find where any of the observation codes say or don't say they can or cannot be used at an ASC. It's not at a hospital, and it's not at an office so I'm stumped!! Thanks for any input.

 

[Pam Warren]

99235 is for OP hospital observation (admitted for observation) subsequent visits. Try using an outpatient consultation code if the payer allows and your documentation criteria is met (three R's), 99241-99245, or a new patient visit 99201-99205 depending on your physician's documentation.

Since the dialysis access codes are minor procedures, you may be bumping up against a bundling edit. CCI tells us that an E&M on the same day as a minor procedure (in this case 0 day global), is not always separately reportable, even for a new patient. Payers differ on whether or not they'll pay based on the reporting of the -25. I think this is likely your issue, and not the observation code.

Hope this helps.