Wiki Observation Coding

jhaider

New
Messages
5
Location
Zephyrhills, FL
Best answers
0
I am having the hardest time getting ANY observation claims paid all of a sudden. We are consulting physicians so we never "admit/discharge" patients. We have been using 99243-99245 with the hospital outpatient location for all our commercial payers. Now they are all of a sudden rejecting, what code set should I be using.. 99224-99226 or 99201-99205, 99212-99215? Any advice would be greatly appreciated. Thanks.
 
Sounds like it would be Subsequent Observation Care codes 99224-99226 if you're caring for patients in observation status. I'm confused about you saying they are "consulting physicians" though. Are they actually getting requests for consults that are requesting reports or recommendations back to the physician requesting the consult?
 
I am having the hardest time getting ANY observation claims paid all of a sudden. We are consulting physicians so we never "admit/discharge" patients. We have been using 99243-99245 with the hospital outpatient location for all our commercial payers. Now they are all of a sudden rejecting, what code set should I be using.. 99224-99226 or 99201-99205, 99212-99215? Any advice would be greatly appreciated. Thanks.
The key word here for me is "Consultation". You may not be aware but CMS did a three year study on "consultations" and 95% of the time a consultation code was used, it was not supported in the documentation. Due to this CMS stopped paying for consultation codes and now most private insurance has followed them. How you were getting them paid at this point is beyond me. It's probable that the insurance companies have performed internal audits and adjusted their software to deny these codes now.
 
In my experience, most payers will only reimburse the observations codes 99224-99226 to the attending physician who is supervising the patient in observation status. If the payer does not accept consultation codes, the other physicians who consult or evaluate and treat the patient during the observation period will need to bill the outpatient E/M codes from the 99201-99215 range.
 
Top