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Observation services

  1. Default Observation services
    Medical Coding Books
    I work with a hospitalist group, and we often bill services for patients in observation. We are having an issue when the patient is in for more than 2 days. Independence Blue Cross is denying the 99213 - 99215 for a referral when we use these codes for the subsequent visits. They do not accept the new codes 99224 - 99226. I know these codes are only to be billed by the admitting or supervising physician, often times we do not fit into this category, so need to bill using the 99213 -99215. I am being advised by the network coordinator that based on our contract we are obligated to bill these services the way they tell us to. They are also indicating that the 99213 - 99215 are strictly office visit codes. I have reviewed the CPT Book and the CMS guidelines, and all the information I am finding indicates that billing these codes is appropriate. I have also reviewed the billing and more than 90% of the time we are getting paid. I would welcome opinions and advice as to how to handle this issue.

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by maine4me View Post
    I work with a hospitalist group, and we often bill services for patients in observation. We are having an issue when the patient is in for more than 2 days. Independence Blue Cross is denying the 99213 - 99215 for a referral when we use these codes for the subsequent visits. They do not accept the new codes 99224 - 99226. I know these codes are only to be billed by the admitting or supervising physician, often times we do not fit into this category, so need to bill using the 99213 -99215. I am being advised by the network coordinator that based on our contract we are obligated to bill these services the way they tell us to. They are also indicating that the 99213 - 99215 are strictly office visit codes. I have reviewed the CPT Book and the CMS guidelines, and all the information I am finding indicates that billing these codes is appropriate. I have also reviewed the billing and more than 90% of the time we are getting paid. I would welcome opinions and advice as to how to handle this issue.
    The description of 99212-99215 is Office or Other Outpatient visitsand if you are billing with an outpatient place of service, you should be just fine.

    In the CPT book instructions for Initial Observation Care it states, "For observation encounters by other physicians, see Office or Other Outpatient Consultation codes (99241-99245)." Perhaps that is what the payer is looking for instead?
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. Default
    Thanks Arlene. I was starting to think I had been coding these wrong, and that I was missing something.

  4. Default travo
    Double check your POS ..... maybe that could be it?

  5. #5
    Location
    Ellenville, New York
    Posts
    1,176
    Default Patient status?
    It could be possible that while the patient was in observation status when your doctor saw the patient, if the status changed to inpatient later, could the carrier be looking for initial, subsequent, or consultation inpatient codes?

    Another thought - what are your state's regs on observation status? Is there a time limit, such as what we have in NY where a patient can be in observation for 8 hours before either becoming inpatient or being discharged? That may be a part of this as well.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

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