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99226 Hospital Observation

Carlos Posted Tue 11th of July, 2017 12:53:21 PM
We have received many denials from Humana insurance regarding observation code 99226 indicating that Authorization referral required. But patient was seen at the Hospital and they are saying no authorization required for observation code therefore the Hospital never got one. we are billing with POS 22 since is observation but Humana representative insist that the specialist should have a referral for out patients services. How do you suggest we should bill this? Thank you
SuperCoder Answered Wed 12th of July, 2017 07:36:29 AM

Check your documentation, how did you process the initial observation care code as 99226 is for subsequent observation care. As per coding guidelines, initial code is billed first followed by the subsequent codes on subsequent days.

Usually, the physician gives the authorization of subsequent observation care on the medical documents of initial observation care (99218-99220).

Carlos Posted Wed 12th of July, 2017 16:19:51 PM
Yes we are also billing initial observation 99220 and for subsequent 99226 but both codes are being denied. As I mentioned before this is happening with Humana insurance only we are billing POS 22 out patient.
SuperCoder Answered Thu 13th of July, 2017 02:59:22 AM

As per Humana Insurance, pre-authorization is required for observation stays.

Get in touch with the insurance for pre-authorization.

 

For reference, follow the below mentioned link

 

http://www.ismanet.org/pdf/education/cpf/humana_2014ismacpf_all.pdf  ( page-4 )

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