Wiki Medicare Risk Subsequent visits POS 22

[tamjohn68]

We are a cardiology practice and are having stuggles with one of our Medicare Risk plans denying 99225 or 99226 visits. We have been instructed by our billing company that this plan has it's own "rules" and they will only accept one subsequent visit code per day regardless of provider or diagnosis. We have been instructed to change our denied codes to office visit codes 99213 or 99214. I believe this advice to be incorrect. If Medicare Risk plans follow CMS guidelines then it would be inappropriate to change these codes in my opinion. I am curious if any other specialist office is struggling with billing for their services/visits on hospital outpatient/OBS codes? And, am I incorrect in thinking we should continue to bill these codes and appeal these denials? Any thoughts or experiences/suggestions on this topic will be very appreciated!

 

[thomas7331]

When Medicare eliminated consultation codes in 2006, they imposed a limit on the observation care codes to only allow these to be billed by the admitting/attending physician. If your provider is the physician who admitted the patient to observation and is overseeing the care, then you can bill the subsequent visit codes but you will need to append an AI modifier to indicate that your physician is the attending. If, however, your provider is a consulting physician, the billing company is correct that you should be billing outpatient codes, 99201-99215, since only the attending may bill the observation care codes.

I'd recommend reading through the MLN article which addresses this in detail - you can find it here: https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/MM6740.pdf

 

[meghanhannus]

We are a cardiology practice and are having stuggles with one of our Medicare Risk plans denying 99225 or 99226 visits. We have been instructed by our billing company that this plan has it's own "rules" and they will only accept one subsequent visit code per day regardless of provider or diagnosis. We have been instructed to change our denied codes to office visit codes 99213 or 99214. I believe this advice to be incorrect. If Medicare Risk plans follow CMS guidelines then it would be inappropriate to change these codes in my opinion. I am curious if any other specialist office is struggling with billing for their services/visits on hospital outpatient/OBS codes? And, am I incorrect in thinking we should continue to bill these codes and appeal these denials? Any thoughts or experiences/suggestions on this topic will be very appreciated!

Hello tamjohn68,

Could possibly your Cardiology providers not be the Observation Care supervising physician (provider who admitted to observation)? According to CMS providers other than the supervising provider should report outpatient service codes which would correlate with your MCR Risk plan requesting the re-bill as 99213/99214. Please check out this CMS link for more information https://www.cgsmedicare.com/partb/mr/pdf/observation_serv_factsheet.pdf .

I hope this helps clarify

M.Hannus, CPC, CPMA, CRC

 

[meghanhannus]

When Medicare eliminated consultation codes in 2006, they imposed a limit on the observation care codes to only allow these to be billed by the admitting/attending physician. If your provider is the physician who admitted the patient to observation and is overseeing the care, then you can bill the subsequent visit codes but you will need to append an AI modifier to indicate that your physician is the attending. If, however, your provider is a consulting physician, the billing company is correct that you should be billing outpatient codes, 99201-99215, since only the attending may bill the observation care codes.

I'd recommend reading through the MLN article which addresses this in detail - you can find it here: https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/MM6740.pdf

Hello Thomas,

I thought that modifier AI was only to be used on an admitting or attending physician who oversees the patient's care during a hospital admission for initial inpatient hospital care e/m service CPT 99221-99223 or initial nursing facility e/m service CPT 99304-99306 or Critical Care CPT 99291 and not Observation codes?

 

[tamjohn68]

When Medicare eliminated consultation codes in 2006, they imposed a limit on the observation care codes to only allow these to be billed by the admitting/attending physician. If your provider is the physician who admitted the patient to observation and is overseeing the care, then you can bill the subsequent visit codes but you will need to append an AI modifier to indicate that your physician is the attending. If, however, your provider is a consulting physician, the billing company is correct that you should be billing outpatient codes, 99201-99215, since only the attending may bill the observation care codes.

I'd recommend reading through the MLN article which addresses this in detail - you can find it here: https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/MM6740.pdf

In my experience, payors do not like to pay 99214 or 99215 with POS 22 and additionally if they do pay they assign copayments to the patient for these codes even though the POS is the hospital. I was understanding more than one provider is able to bill 99225 or 99226. I completely understand not to bill the initial visit. Do you still believe billing office visit codes is the most appropriate course of action?

 

[tamjohn68]

Hello tamjohn68,

Could possibly your Cardiology providers not be the Observation Care supervising physician (provider who admitted to observation)? According to CMS providers other than the supervising provider should report outpatient service codes which would correlate with your MCR Risk plan requesting the re-bill as 99213/99214. Please check out this CMS link for more information https://www.cgsmedicare.com/partb/mr/pdf/observation_serv_factsheet.pdf .

I hope this helps clarify

M.Hannus, CPC, CPMA, CRC

Thank you for the link - much appreciated.

 

[thomas7331]

I've worked for a number of years for a hospital and multispecialty physician group that bills E&M services extensively with place of service 22 and I have never experienced what you're describing that 'payors do not like to pay 99214 or 99215' with this POS. Of course, payers don't really 'like' to pay anything at all unless they have to, but that shouldn't determine code choices. As for the application of copays - that is driven by patient benefits and not by coding, and if they are applying incorrect copays, that is their error and not the coders'. The codes 99201-99215 (which incidentally are not 'office visit' codes but rather 'office or other outpatient visit' codes per the CPT description) are correct codes for E&M services by providers other than the attending/admitting physicians in an outpatient setting other than the emergency department, for payers that follow the CMS guidelines. Certainly, other non-Medicare payers may have different requirements.

 

[thomas7331]

Hello Thomas,

I thought that modifier AI was only to be used on an admitting or attending physician who oversees the patient's care during a hospital admission for initial inpatient hospital care e/m service CPT 99221-99223 or initial nursing facility e/m service CPT 99304-99306 or Critical Care CPT 99291 and not Observation codes?

Yes, you're correct, I composed my response in too much of a hurry. The AI modifier is only required for inpatient services in order to distinguish initial visits of the attending from those of consultants. For outpatient, although the AI is allowed, only the attending may bill the observation codes and other physicians bill the outpatient codes so it is not necessary.

 

[meghanhannus]

Thank you for the link - much appreciated.

You're welcome

 

[meghanhannus]

Yes, you're correct, I composed my response in too much of a hurry. The AI modifier is only required for inpatient services in order to distinguish initial visits of the attending from those of consultants. For outpatient, although the AI is allowed, only the attending may bill the observation codes and other physicians bill the outpatient codes so it is not necessary.

I understand Thank you for clarifying