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Denials for 99220 Observation consults

Jani Posted Tue 15th of January, 2019 12:29:59 PM
We are getting denials for cpt code 99220 Observation consult- being told that this code is only billable by one physician per admission. Our question is when the hospitalist/admitting doctor files a claim with 99220 how does our specialist (urologist), who is in solo practice and unaffiliated with the hospital group, code for his initial visit/consult with the patient under observation care? When we get denied with 99220 and we adjust using the AF modifier we are still getting denied. Should we bill with 99234, 99235 or 99236 even though it is the initial consult by our doctor and not subcare that we are seeking to bill? Please advise. We have sent in corrected claims along with medical records and are still getting denied. The insurance companies are denying based on "following cms guidelines" yet medicare does not deny our 99220 claims.
SuperCoder Answered Wed 16th of January, 2019 07:30:28 AM

New or Established Patient Initial Hospital Observation Care Services codes (99218-99220) are used to report evaluation and management services provided to patients designated/admitted as "observation status" in a hospital. It is correct that these codes can be billed only by one physician per admission. If your doctor (Urologist) is admitting the patient, then he has to bill it not the other one. If hospital's doctor admitted the patient and your doctor also consulted, then it will be denied for initial visit/admission.

Whereas, code range 99234-99236 are used for observation or inpatient hospital care for same day admission and discharge. But, this service also be paid only one physician per DOS, admission and discharge.

AF modifier also will not help here to get the payment for both the doctors. Modifier AF is a Medicare use only modifier that represents the services of a specialty physician in a physician scarcity area, or a geographic area with a shortage of primary care doctors or specialists available to the Medicare population in that area. Use of this modifier provides for a quarterly bonus payment along with claim payment.

In this case, you need to check who actually admitted the patient and provided the services, if your doctor (Urologist)  admitted the patient and other doctor (Hospital's doctor) claimed the payment, then on your report, payer need to recoup the payment from hospital's doctor and give it to you, otherwise you can directly get in touch with the hospital for mutual settlement.

Hope this helps

Jani Posted Thu 17th of January, 2019 08:51:09 AM
Thank you for your response. To be clear, when our doctor (urologist) is not the admitting doctor but does his initial consult on an observation admission what cpt code range should be used if his initial consult is not performed on the same day as admission and discharge?
SuperCoder Answered Fri 18th of January, 2019 06:10:00 AM

As per AMA guidelines, 99218-99220 code range is used to report the encounter(s) by the supervising physician or other qualified health care professional with the patient when designated as outpatient hospital "observation status. "This refers to the initiation of observation status, supervision of the care plan for observation and performance of periodic reassessments. For observation encounters by other physicians, see office or other outpatient consultation codes (99241-99245) or you also check subsequent observation care codes (99224-99226) if your doctor is providing the services on subsequent days.

Hope this helps!

Jani Posted Thu 31st of January, 2019 14:44:44 PM
Thank you for your response...I now need to clarify if the codes 99234, 99235 and 99236 that I will use for our doctor (not the admitting doctor) for observation consults are only allowed to be used once per admission as a cpt code series or if 99234 can be used once by a doctor and 99235 as well as 99236 can also be used during the same visit but by a second and a third doctor? I understand that the 99220, 99219 and 99218 are to be used by the admitting dr only but if there is more than one supporting doctor consulting the patient during the same observation visit how can I ensure that our dr gets paid if the admitting dr uses the 99218-99220 series and one of the supporting doctors has already used a code from the 99234-99236 series? I am trying to understand what billing options I have when our dr is one of many consulting doctors (other than the admitting dr) for a single observation stay that requires the consult of more than one supporting dr.
SuperCoder Answered Fri 01st of February, 2019 07:02:01 AM

CPT code range 99234-99236 is for observation or inpatient hospital care, including admission and discharge on the same date, yes, this series it to be used once per admission and discharge by a doctor, 99235 and 99236 can also be used according to the elements by admitting physician. For 99235- required elements are-History-Comprehensive, Exam-Comprehensive and MDM-Moderate and for 99236-History-Comprehensive, Exam-Comprehensive and MDM-High. Whereas, code series 99218-99220 is for initial observation care-by one physician only, 99224-99226 if for subsequent observation care- this can be billed by another physician than admitting physician.

When there is more than one supporting doctor consulting the patient during the same observation visit, then only mutual understanding plays a role to pay to both the physician, payer will reimburse the amount only to one physician, however, code range 99218-99220 and 99234-99236 cannot be billed together for same DOS by any physician.

Hope this helps!

Jani Posted Wed 13th of February, 2019 11:53:38 AM
Okay, to clarify: When our doctor (urologist) is not the admitting dr but has been requested to consult a patient under observation care what code range do we use for the initial observation consult. Is it code range 99241-99245? If so, what are the subsequent follow up services coded as? Would that be 99211-99215? I am asking about what our initial consult code as well as our subsequent follow up codes would be not what the admitting doctors codes would be. Thank you
SuperCoder Answered Fri 15th of February, 2019 08:06:26 AM

As per CMS, “Effective January 1, 2010 Medicare does not recognize consultation E&M CPT codes 99241–99255 for billing and payment purposes.  If a physician performs a consultation E&M, the physician may report the appropriate level of E&M service for the site of service where the consultation E&M occurs.”

 

For payers who do not follow Medicare guidelines; if a patient is consulted before the admission to the hospital (e.g. in the observation), then physician should report outpatient consultation codes (99241–99245).

 

These codes do not say “initial” or “subsequent”. So, for subsequent consultations, physician should report outpatient consultation codes (99241–99245).

 

Hope this answers your query.

SuperCoder Answered Fri 15th of February, 2019 08:06:51 AM

Please feel free to write if you have any question.

 

Thanks

Jani Posted Fri 15th of February, 2019 08:56:38 AM
Hi. I'm sorry but this still does not answer my question. Per CMS guidelines what is the code series that I bill in order to get my doctor (urologist) paid when he is requested by the admitting doctor for an observation consult? I am still unclear what code range to use when the admitting doctor requires the consult of my doctor for a patient under observation status when the insurance is medicare or any other insurance that follow CMS guidelines. What would the consult code range be for my doctor under these circumstances as well as what would the code range be for subsequent care for my doctor under these circumstances??
SuperCoder Answered Mon 18th of February, 2019 08:01:40 AM

Hi,

 

Please find answers to your questions incorporated in your text (in bold):

 

Hi. I'm sorry but this still does not answer my question.

 

  1. Per CMS guidelines what is the code series that I bill in order to get my doctor (urologist) paid when he is requested by the admitting doctor for an observation consult? --- 99201-99205 for New patients.
  2. I am still unclear what code range to use when the admitting doctor requires the consult of my doctor for a patient under observation status when the insurance is medicare or any other insurance that follow CMS guidelines. --- 99201-99205 for New patients.
  3. What would the consult code range be for my doctor under these circumstances as well as what would the code range be for subsequent care for my doctor under these circumstances?? ---  --- 99211-99215 for Established patients.

 

Hope this helps.

 

Thanks

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