Wiki Observation Setting/POS

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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..
 
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.
 
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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