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Several Questions

  1. #1
    Default Several Questions
    Medical Coding Books
    1. When using 1700 and 17003. We do charge an office visit with modifier 25. Then 1700 by itself. 17003 w/modifier 59, but the units are (lets say) 2. Now the CPT guidelines state to list them separately. I have tried both ways but have not been able to get the 17003 paid.

    2. Patient comes to clinic has an ekg, or other tests, performed and was admitted. Now all of sudden! ins is denying the initial admit due to office charges. Does modifier 27 apply to this situation and does it attach to the hospital admit?

    3. I am instructed to code as outpatient, pos 22, if pt is admitted for chest pains but the discharge is 21. I am confused on that "direction!" Does it really matter why a pt was admitted to direct what is in/out patient?

    Thanks for your response.

    Judy

  2. #2
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    Columbia, MO
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    Quote Originally Posted by msjudy71655 View Post
    1. When using 1700 and 17003. We do charge an office visit with modifier 25. Then 1700 by itself. 17003 w/modifier 59, but the units are (lets say) 2. Now the CPT guidelines state to list them separately. I have tried both ways but have not been able to get the 17003 paid.

    2. Patient comes to clinic has an ekg, or other tests, performed and was admitted. Now all of sudden! ins is denying the initial admit due to office charges. Does modifier 27 apply to this situation and does it attach to the hospital admit?

    3. I am instructed to code as outpatient, pos 22, if pt is admitted for chest pains but the discharge is 21. I am confused on that "direction!" Does it really matter why a pt was admitted to direct what is in/out patient?

    Thanks for your response.

    Judy
    1. To bill an office visit with any procedure you must make certain you have met the parameters of the 25 modifier, in short the office visit must be over, above, and beyond the evaluation for the necessity of the procedure. Second when you are billing multiple lines of an add on code, the 59 goes on the second one
    17000
    17003
    17003-59
    2. You cannot bill an office visit and an admit on the day. The 27 modifier is for the facility, it cannot be used for physician billing. You may bill the admit with a 25 modifier and your EKG
    3. If the patient is a direct admit the will be no outpatient charge for your provider ou bill only inpatient POS 21. Only if you admit to observation will you use a 22 modifier as observation is outpatient. If the provider converts the patient to inpatient status after they have been discharged then you will need to submit a corrected claim for you admit and convert it to inpatient.
    I assumed you were inquiring regarding physician billing, if not then let me know.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
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    Debra,

    Thank you for the information.

    On the admit, there is no office visit, just the ekg or lab that resulted in the patient being admitted from the office. But when the hospital charges are submitted, it is rejected because it is, in there words, included in the procedure from the office. Does that make since? One insurance person stated that a modifier would be needed for either the ekg or hospital admit charge but would not say what modifier. After research, I want to assign 27, but not sure to which it needs to be attached to.

    Judy

  4. #4
    Location
    Columbia, MO
    Posts
    12,913
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    Quote Originally Posted by msjudy71655 View Post
    Debra,

    Thank you for the information.

    On the admit, there is no office visit, just the ekg or lab that resulted in the patient being admitted from the office. But when the hospital charges are submitted, it is rejected because it is, in there words, included in the procedure from the office. Does that make since? One insurance person stated that a modifier would be needed for either the ekg or hospital admit charge but would not say what modifier. After research, I want to assign 27, but not sure to which it needs to be attached to.

    Judy
    The 27 modifier may be assigned by facility coders only, when they are coding for the facility. It is used when the facility has more than one clinic or ER encounter with the same patient on the same day. It would not apply in this scenario even if you were coding for the facility.
    It is true that many time a payer will bundle the EKG and the visit together especially if the dx is chest pain. You can try to resubmit, use a 25 on the admit level with a POS of 21 and the EKG with a POS of 11 if it still bundles you may need to look at a higher level appeal or accept that it is bundled.

    Debra A. Mitchell, MSPH, CPC-H

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