Observation POS

spirving

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CPT states that observation codes are used in a "partial hospital setting". Is there a hard and fast rule or documentation somewhere about whether observation codes should utilize POS 22? That was always my interpretation but now I'm not so sure. My research on the issue still leaves me with inconclusive answers....
 

Kris Cuddy

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It is my understanding the observation codes are hospital observation. The patient is typically admitted to observation status, but not admitted to the hospital. This would make the appropriate place of service as 22.

CPT describes them as Hospital Observation Services. Also indicating that even if the patient who is admitted to observation status is not in a designated observation area, bill the hospital observation services E/M codes.

Examples could be:

1) Mrs. Jones is admitted into observation status at yoohoo hospital. Yoohoo hospital has an observation unit and has an open bed. Dr. A is the one who admits Mrs. Jones into observation status and, based on his documentation, bills 99219 as the intial observation care code. The following day, Dr. A visits Mrs. Jones and she is doing so much better, Dr. A decides to discharge Mrs. Jones from observation status and send her home. Dr. A bills 99217 for the observation care discharge.

2) Mrs. Jones is admitted into observation status at yoohoo hospital. Yoohoo hospital has an observation unit but does not have an open bed. Dr. A is the one who admits Mrs. Jones into observation status. Dr. A admits Mrs. Jones into observation status but keeps Mrs. Jones in the emergency room, hoping a bed in the observation unit will become available. Based on his documentation, bills 99219 as the intial observation care code. The following day, Dr. A visits Mrs. Jones, she is still in the emergeny department as no bed became available through the night or morning. Mrs. Jones is doing so much better, Dr. A decides to discharge Mrs. Jones from observation status and send her home. Dr. A bills 99217 for the observation care discharge.

The only difference between example 1 and 2 is the actual physical location of where the patient was in the facility. The patient was admitted into observation status. Observation status is just that, a status of being partially admitted for observation only. It does not matter where the patient is physically at within the facility. It's the status of whether they were admitted into observation, admitted as an inpatient, or an emergency room patient, etc., that will guide the selection of E/M codes for observation, inpatient, ER, etc., the place of service will follow the patient's status.

Hope this helps.

Kris
 

spirving

Networker
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Great info! I agree, and thanks. The problem that is happening is that some carriers are stating that these cpts are not appropriate for POS 22. As coders we understand the reasoning but as far as finding some specific documentation that we can argue with is my difficulty.
 

Kris Cuddy

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If I were to argue a carrier response like that, I would ask for a statement in writing, providing either their legal written policy of observation care billing, or a legal statement indicating why they are not required to pay for these services with POS 22. Specifically when federal insurance carriers, such as Medicare, and state payors, such as Medicaid, allow, pay and submit POS 22 as appropriate for hospital observation care E/M services.

Also, I would give the carrier a deadline to reply by, perhaps 14 to 30 days. In addition, I would advise the carrier, in the same letter, that after that time-frame, this matter would be turned over to our company's legal counsel for resolution.

I have been known to not only cc the provider of the services on the letter, yet the patient too.

Whatever you write in a letter, the message to the carrier should be loud and clear, without being abusive, that you expect either legal documentation of why they won't pay, or payment. That is that.

Perhaps also check your states clean claim laws and find out how timely carriers are supposed to be paying clean claims under the prompt payment laws. Maybe reporting the carrier for inappropriate actions is also in your providers best interest.

It's becoming ridiculous how much we have to fight, at times, to have things paid appropriately. There are carriers out there who will attempt many elusive maneuvers attempting to get away without paying. It's our responsibility to take a stand and not allow that to happen, by saying to the effect that we want them to prove to us why they should not have to pay something when other carriers are paying - specifically when we know in our hearts it is truly reimbursable.

Ok, I am getting off my soapbox now, LOL. It just burns me when a carrier blatantly tries to not reimburse services that are truly deserving reimbursement. Hope you have a great day:D

Kris
 

caroline

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observation POS

Can we use POS 22 for ADMIT and Disharge on same day (99234-99236)?

Thanks
 

mitchellde

True Blue
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No 22 may not be used for admit no matter the length of time. Admit to inpatient takes a physician order just like admit to observation. There are certain procedures that are inappropriate for the outpatient setting and will not be paid if that was the place of service. But we code based on the documentation.
 

mitchellde

True Blue
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I sorry I was answering the other question, yes it can be used either but it must match the documentation. If the documentation states admit then it is POS 21 if it states admit to observation then POS is 22.
 
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Rock Hill, SC
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Question

Good morning,

I have read the older posts about the POS that should be used for observation in a hospital setting. However, what is the policy for entities that operate 24 hours/day who may have the need to hold patients for observation based on patients' conditions? Other than 22, is there another place of service code that can be used when billing 99218-99220?

Thank you.

Marilyn
 
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