Wiki Observation Codes - Medicaid

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maryv22

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Hello,

I am hoping I can get some feedback regarding the coding and billing of Hospital Observation codes for Medicaid patients.

According to the HFS Handbook for Practitioners (Observation Section A-220.4) - http://www.hfs.illinois.gov/assets/a200.pdf - "Payment will not be allowed for observation care for consecutive dates of service. Also, only one observation CPT Code may be billed. The observation care "discharge" is not a covered service."

Since Medicaid does not accept Observation subsequent visits and discharge, would alternative coding be acceptable? For example, bill outpatient established visit codes (99211-99215) instead of observation subsequent codes and discharge (99224-99226/99217)?

Mary V., RHIA, CPMA
 
Since IL Medicaid has clearly stated that they will not pay for consecutive dates of service, attempting to circumvent this by changing the coding of claims, in my opinion, could potentially be construed as fraud or abuse. If your organization is seriously considering doing this, I would get recommend getting clarification in writing from the Medicaid plan since they are the organization that would be paying the claims, and not rely on individual coder opinions as to whether or not it is acceptable.
 
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