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Thread: 99285 Acuity Caveat

  1. #1
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    Default 99285 Acuity Caveat

    Can anyone tell me where the wording in the 2010 CPT book defines the 99285 acuity caveat? I'm being told that it no longer exists and I want to verify if that is true or not?
    Evangelina Frohna, CPC, CEMC

  2. #2
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    Default acuity caveat

    It has always been written under the 99285 CPT descriptor:
    ...."requires these three key components witin the constraints imposed by the urgency of the patient's clinical condition and mental status."

    Will this help with what you're looking?

    Each regional Mediare carrier apply the caveat differently, so check with their requirements on what parts of the E/M they allow the application.

  3. #3
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    Default

    Hi Michelle,
    Thanks for responding. That is what I thought as well. I don't know what State you are in? I'm in Wisconsin, and the acuity caveat is not allowed for WPS-Medicare, but it still stands for non-Medicare. I was at a recent coding symposium in WI this past Fall and this same issue was brought up & the ED Physician said it was still valid. However, after further research it is not valid for Medicare anymore.
    ~Vangie
    Evangelina Frohna, CPC, CEMC

  4. #4
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    Default History

    Evangelina,
    I believe you are referring to counting the ROS and PFSH as complete when the physician documents the reason it cannot be completed (e.g. patient in coma, no family members present).

    Yes, WPS Medicare requires us to use the 99499 Unlisted E/M service, and charge the equivalent fee of the E/M we WOULD have charged had the history been complete.

    For example ... if you had a comprehensive exam and high MDM with a critically injured patient who was unresponsive (so you couldn't get a complete history), you would use 99499 but base you fee on 99285. (Of course if you provided critical care of 30 minutes or more, you could use the 99291-99292 codes instead.)

    Wouldn't it be nice if everyone did things the same way!? (When they let me rule the world, that will be the first rule I implement ... well, right after chocolate not having any calories.)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
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    Default

    Hi F. Tessa,
    Yes, we are on the same page! We would take the 99499 and equate to the level the physician initially selected. On the back end of this, Medicare is still denying and we are appealing with a copy of their own rule. This has not been fun, but we're doing our best compliance-wise. Thanks for your input!
    Evangelina Frohna, CPC, CEMC

  6. #6

    Default

    does anyone have a link for WPS where this policy is found? I just talked to them and was told there was no such policy about the level 5 caveat.
    thanks

  7. #7
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    Default

    Quote Originally Posted by glenski91175 View Post
    does anyone have a link for WPS where this policy is found? I just talked to them and was told there was no such policy about the level 5 caveat.
    thanks
    Glenski91175, I believe where all the confusion comes in is in the description of 99285 in the CPT book it defined...."requires these three key components witin the constraints imposed by the urgency of the patient's clinical condition and mental status." This was considered the 99285 caveat by the Wisconsin Medical Society, and a lot of ED physicians used this as well. However, WPS-Medicare does not recognize this anymore, and it was removed from WMS website. Hope this helps.
    Last edited by efrohna; 05-13-2010 at 12:48 PM. Reason: More detail
    Evangelina Frohna, CPC, CEMC

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