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Observation

  1. #1
    Default Observation
    Medical Coding Books
    Can anyone help with this one? I have an edit showing up on an observation account using the 99220 CPT. Thee CPT code 96360 was also charged and it is saying that it requires an NCCI modifier in order to bill together. Why is that? I know that with Obs charts, you can not bill any other E&M services, but I am not aware of any problems billing hydration along with Obs accounts. Anyone??

  2. Default
    Are you coding for the facilty or for the physician?

    If you;re coding/billing for the physician, you would not code for the IV cause you're using facility supplies and the facility will bill for their supplies and services. You would code only the 99220 OBSV E&M service that your physician provided

    If you're coding for the facility...well you will need to get input from someone who codes that side

    But in general, if the documentation supports, you need to add mod -25 to the E&M. Documentation must show that there was a significant separate E&M service performed in addition to the CPT service

  3. #3
    Default
    I am coding for both on this case.

    Is it common to use a -25 on observation codes? I've never seen it done before.

  4. #4
    Default
    Anyone else? I could really use some help with this today if anyone can help.

  5. Default
    The modifier -25 can be used on OBSV codes just as any E&M 99210-99255 etc.

    The issue is to make sure the documentation supports that a significant separate E&M service was provided/documented in addition to the CPT service that was provided.

    I guess I am just confused that if this is patient was seen in a facility, you shouldn't be coding the 96360 IV for the physician. That's a facility service. So as long as he did another CPT service in addition to his OBSV visit, then you would code OBSV with mod -25.

    Anyway, you know what service and who you are coding for, so to answer your initial question, yes, mod -25 can be used with OBSV E&M codes with supported by documentation

    Hopefully someone will respond to that codes facility side and give you their view of all this.

  6. #6
    Default
    Quote Originally Posted by sbicknell View Post
    The modifier -25 can be used on OBSV codes just as any E&M 99210-99255 etc.

    The issue is to make sure the documentation supports that a significant separate E&M service was provided/documented in addition to the CPT service that was provided.

    I guess I am just confused that if this is patient was seen in a facility, you shouldn't be coding the 96360 IV for the physician. That's a facility service. So as long as he did another CPT service in addition to his OBSV visit, then you would code OBSV with mod -25.

    Anyway, you know what service and who you are coding for, so to answer your initial question, yes, mod -25 can be used with OBSV E&M codes with supported by documentation

    Hopefully someone will respond to that codes facility side and give you their view of all this.
    I am coding both sides. The facility side and the pro fee side. I know that I am allowed to use a -25, I'm just not sure why I should have to. I am questioning the edit that my encoder is giving me about the 96360 being a component code of the 99220 code, not my coding, see? that's why the dilemna. I am beginning to think that the edit is just wrong in this case. thanks for your help, though.
    Last edited by LTibbetts; 05-28-2010 at 12:24 PM.

  7. #7
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default
    Leslie,

    I checked the CCI edits on the CMS website. For OP Hospital coding, 96360 is column 1 and 99220 is column 2, but a modifier is allowed.

    For the physician, 99220 is column 1 and 96360 is column 2, and a modifier is allowed.

    Of course, since done in OP, you wouldn't bill the 96360 for the physician.

    I hope this helps!
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

  8. Default
    Sorry, mis-understood your question which is "I know that I am allowed to use a -25, I'm just not sure why I should have to. I am questioning the edit that my encoder is giving me about the 96360 being a component code of the 99220 code, "

    So, the reason for the mod -25 is to show that a significant separate E&M evaluation was done at the same time as the CPT or IV service.

    For example, say a patient is ordered to come in for a IV of drugs every 2 days for 3 weeks. That's a planned CPT service and a separate E&M is not allowed.

    But say this patient comes in for his planned IV but says he has been throwing up every day since the last IV treatement. Then there is medical necessity to re-evaluate the patient before stating the CPT service. Then a 99220 is allowed.

    Just because the patient is admitted to OBSV for this service does not mean the 99220 can automatically be coded. Also E&M guidelines still have to be met. Also the 99220 is ther highest complexity of code. Does documentatation support this.

    Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity.

    Adding the mod -25 is the only way for you to show the payer that the eval was a separate service from performing the CPT service. If you submit a 99220 and a 96360 and no mod -25 is used, most likely the payer is going to consider the E&M inclusive to the CPT service and deny the 99220. Most commonly the payer payes the cheapest service when a mod -25 is not used

    Your system is giving you an edit againt the 96360 cause a physicain would not normally code this in the facility setting. It's not his service to code. But you have the documentation and know what they were doing

    Did I do any better this time
    Last edited by sbicknell; 05-28-2010 at 02:28 PM.

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