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Admit to Observation - with an Expanded Problem Focused HPI/History

David Posted Fri 17th of February, 2017 15:21:03 PM
Our providers often are the admitting physician at the hospitals for patient to observation. I know the rules on what codes to bill, but I am unsure of what to bill if our provider performs and H&P for his admission to observation, but fails to meet the documentation requirements of the lowest level 99218. Many times we are finding they have a Expanded/Problem focused History, but will have the Comprehensive Exam and MDM. The problem is all 3 elements are required and they didn't meet the "detailed" history. I have read and been billed 99499 in those cases. Is this correct? Or can we not bill at all considering we didn't meet the documentation requirements. I am concerning about not billing at all....because then what happens when we meet the requirements and bill a subsequent observation visit or discharge on the following dates? Can we bill those charges if no admission charge is billed? I appreciate your feedback. I have done a lot of research and can only find information to use the 99499. But nothing on billing a discharge when we never billed an admit.
SuperCoder Answered Mon 20th of February, 2017 02:45:56 AM

As per CMS since you are unable to meet the components for initial observation care (99218), you should bill subsequent observation code (99224/99225) for your initial observation care services.

CMS has instructed Medicare contractors to not find fault with providers who report a subsequent care CPT code in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent care code (under the level selected), even though the reported code is for the provider's first E/M service. This applies to observation and Inpatient visits.

Please find below the link from CMS for more understanding: 

David Posted Wed 01st of March, 2017 09:31:42 AM
I read this article and I do not see anywhere in it that it states to use subsequent observation codes if you do not meet the initial/admission codes for observation? I know that due to Medicare not accepting consult codes, providers can bill subsequent hospital codes 99231-99233 if documentation does not meet the admission codes 99221-99223. That is very clear and stated in this transmittal that you are referring to. This transmittal does not address observation codes. I am not able to find anything out there supporting billing as you state above. Do you have anything to support that statement? I appreciate your feedback.
SuperCoder Answered Thu 02nd of March, 2017 02:33:42 AM

Since you are unable to meet the components for initial observation care (99218), subsequent observation code (99224/99225) should be billed. This is the most prefered way of billing.

You cannot bill initial observation care because your components are not meeting. Though, not much documentation is available in written, this is the most preferred way to get reimbursed for your services and providers are using it in general practice and are getting reimbursement from insurance companies because they are using a lower dollar value code for the provided services. Insurance companies are okay with it as well.

Hope this information would be helpful.

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