Observation Setting/POS

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104
Location
Huntington, West Virginia
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Question for my fellow coding peeps: Medicare guidelines state that the only time we can bill the observation code is if we are the provider that admitted the patient to observation status. Am I correct on this information? And since we can't use the observation code we would use a new pt or est patient code. Am I correct on that information as well? The reason I am asking is that a payer (The Health Plan) wants us to use the observation code when the provider sees the patient in that setting. This is going against what I have been told. Now I am concerned that I have been doing this wrong. Anytime our provider sees a patient in observation, unless we admit them to obs which we rarely do, I use the new patient or established patient codes. I just want to reassure myself that I am doing this correctly. I appreciate all the help. :(


Signed Bewildered Coder..
 

brightpea

Networker
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28
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i went to a KZA workshop last year and have a few worksheets on this subject. i don't believe you're doing it wrong. i'm going to try to send you a pm with some worksheets that may help you out.
 

thomas7331

True Blue
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3,164
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You are doing this correctly under CMS guidelines that were issued at the time that Medicare stopped accepting consultation codes (link included below), but this is a Medicare-specific requirement. If you are dealing with a non-Medicare payer that still recognizes consultations, they are probably expecting you to submit outpatient consultations codes instead of established patient visit codes for this situation.

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/mm6740.pdf
 
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