Observation and evaluation for a Medicare Patient

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Hello, I just joined AAPC to start training for CPC certification . I have a question that has been bugging me that I can't seem to find an answer to and it may be a dumb one but I have to ask..
I work for an oral surgeons office and went to a AAOMS coding course who said we could use the Z03.89 dx for a non medicare patient and if a patient has the 3 criteria's met: suspected condition, no signs or symptoms of suspected condition and after study, patient does not have the suspected condition. My question is what if its a medicare patient, I know they will deny this diagnosis is there any other to bill? I can't bill the suspected condition alone do I use the Z03.89 code and let it deny and patient is responsible?

Thanks for any help,
Sandy
 

thomas7331

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I don't believe that information is correct - I have never heard of or seen Medicare deny a claim solely based on this diagnosis. If the procedure or service is covered by an LCD or NCD and is being done for a patient with no symptoms, then yes, you may need an ABN or otherwise get a denial, but there is no Medicare policy that I am aware of that would otherwise deny a medical necessary service simply because this was the diagnosis code reported.
 
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Observation

I had claims deny for observation due to the E/M code for POS 22, I used the subsequent observation code, another physician (not ours) had seen and billed, for the same code, same day, Medicare only allows one per day. I corrected the claim to an established out patient code 99214. This situation is recent.

Unsure if I handled this correctly.
 
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Limit Of Days in Observation

Is there a limit to the amount of time a patient can spend in "Observation" status.. I thought it was 24 hours. However I have billed observation to patient that have been in hospital for 5-7 days as observation. Per hospital notes.
 

thomas7331

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Is there a limit to the amount of time a patient can spend in "Observation" status.. I thought it was 24 hours. However I have billed observation to patient that have been in hospital for 5-7 days as observation. Per hospital notes.
The isn't a limit on observation. Medicare does have 'medically unlikely' edits set up for number of hours in observation, but there is no requirement that observation has to be a certain length of time. Patients are admitted to inpatient or observation based on the physician's assessments of their condition and treatment needs at the time of admit, but the actual time can be more or less.
 
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The isn't a limit on observation. Medicare does have 'medically unlikely' edits set up for number of hours in observation, but there is no requirement that observation has to be a certain length of time. Patients are admitted to inpatient or observation based on the physician's assessments of their condition and treatment needs at the time of admit, but the actual time can be more or less.
I have been looking for this on the Medicare website and can't find it. I need it to prove to a Dr that this is the case. Do you have any suggestions?
 

thomas7331

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I have been looking for this on the Medicare website and can't find it. I need it to prove to a Dr that this is the case. Do you have any suggestions?
I don't quite understand what it is you're trying to prove to the doctor - that there is a limit on the time or that there isn't? And are you referring a particular scenario with regard to facility reimbursement and guidelines, or to physician services? Can you clarify the issue a bit?
 
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