Wiki UHC Documentation Review Denial

[SSThomas03]

Has anyone received a documentation review similar to the one below? If so, what were the steps you took to resolve the issue? The claim was submitted with CPT code(s) 99219-57 and 44970 with POS 22. Ironically, code 44970 was paid.

"Not supported. The submitted medical records do not indicate that the patient is designated or admitted as observation status. A designation of observation status is required to support this code."

 

[thomas7331]

In my experience, appendectomy patients are not usually admitted to observation status (which requires an admission order in the chart), and that appears to be the reason for the denial. If the patient was not admitted, then the E&M service that resulted in the decision for surgery should be based on the place of service where the surgeon initially saw the patient prior to surgery which would be in the code range 99281-99285 (if in the emergency room) or 99201-99215 (if in the office or other outpatient facility setting).