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99223 and 99233

Carlos Posted Fri 02nd of September, 2016 15:50:58 PM
Medicaid denied CPT 99223 and 99233 billed with different DOS due to Adjustment Reason Code 16 : Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. When billing company called them they said it was denied for missing modifier. do these two CPT need a modifier for Medicaid patients?
SuperCoder Answered Mon 05th of September, 2016 01:59:18 AM
  • In the inpatient hospital setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304 – 99306). Contractors consider only one M.D. or D.O. to be the principal physician of record (sometimes referred to as the admitting physician.) The principal physician of record is identified in Medicare as the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. Only the principal physician of record shall append modifier “-AI”, Principal Physician of Record, in addition to the E/M code.
  • Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits.You report the appropriate initial code that supports the documentation. As for the admitting MD, he reports the initial visit with AI modifier to indicate that he/she is the admitting MD. This is how Medicare differentiates between the admitting and another MD rendering service.
  • If your physician is the admitting MD, report the initial, inpatient visit (supported by documentation) with the AI modifier. (again, assuming this is inpatient)
Carlos Posted Wed 07th of September, 2016 13:27:30 PM
How about Humana patients? They denied one claim with CPT 99223 because they are saying the service is not payable to specialist, it is payable only to PCP/admitting provider only. We are specialists
SuperCoder Answered Thu 08th of September, 2016 03:31:37 AM

99221-99223 are codes that ONLY the doctor who admits the patient as inpatient can use. Those are inpatient admission codes ONLY.

If your doc was asked to do a consult on an inpatient then you would use codes 99251-99255 with the inpatient hospital place of service (21).


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