Wiki Coding 99499 in addition to another E/M code when patients are seen within 14 days of hospital visit.

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AmandaDumas

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Hello all!

Would it be valid to report CPT 99499 - Unlisted Evaluation and Management service
WITH another CPT code 99202-99205 when a patient comes to the practice as an outpatient within 14 days of a hospital visit?
So if they were recently discharged from the hospital 3 days ago and see one of our providers in that time frame, can we bill for a 99204 AND a 99499 or 99214 AND a 99499 on the same date of service?
It doesn't make sense to me to bill this way but someone at the office is asking us Coders to do this. Does anyone have any literature on the topic that I can send to explain why I personally think it is a bad idea??
I have already read what I could but I can't find any information blatantly saying that we CANNOT do this.

If the provider is following up with a patient in an outpatient setting after they were recently discharged from the hospital, then the E/M 99202-99215 would fall under that service without the need for anything additional, in my opinion.

But I'm also waiting to hear back from the team to see if this request is coming directly from and insurance company as there was mention of insurance companies trying to improve on patient outcomes, post hospitalization.

Please advise! Thank you in advance. This one is interesting.
 
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I have the same question - what are you using unlisted 99499 to represent?
Per Noridian, you should not be using 99499 along with an E/M service. Unlisted is specifically for a situation where there is no code for the service provided.
If the clinician spends additional/significant time reviewing hospital records, reconciling medications, updating active problems in your EHR, etc., the note should indicate how much total time spent on the day of the encounter, and you may get a higher level than billing on MDM.
 
In addition to what others have said;
  1. Even though there may not be a specific rule that forbids what you're being asked to do, there are overarching rules that require accurate coding. If the provider is doing work described by another code, the unlisted code is inappropriate.
  2. After you submit a claim with an unlisted code your payer will ask you to submit additional documentation. So the providers must create that documentation and the practice must be prepared to track these claims, respond to requests and follow up with payers. That documentation will need to show the work for the unlisted code isn't covered by any of the other codes available.
  3. Payers decide how much they'll pay for unlisted codes or if they'll pay them at all.
  4. Just my opinion, but I don't see how an unlisted code could help with patient outcomes.
  5. For Medicare patients there's also this excerpt from IOM 100-04, chap 12

    Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited tocases where there is no other specific E/M code payable by Medicare that describes that service. Reporting CPT code 99499 requires submission of medical records and A/B MAC (B) manual medical review of the service prior to payment. A/B MACs (B) shall expect reporting
    under these circumstances to be unusual.
 
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