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Observation codes

Vaida Posted Tue 18th of November, 2014 17:31:31 PM

Hi, I have a physician, who performs photopheresis procedures on patients. He usually bills 99235 (mod 25) with 36522 on one day and then again 99235 (mod 25) with 36522 on the following day. Medicare always pays both 36522 codes, but only one 99235 code. The other one gets denied for frequency. Would you have any input on this, please?

SuperCoder Answered Tue 18th of November, 2014 19:21:24 PM

Thanks for your question. You are to report 99235 if the provider admits the patient to observation or to an inpatient status and discharges him on the same day. Inpatient status includes a minimum of 8 hours, but less than 24 hours. When selecting an E/M service level for observation or inpatient hospital care, there are three key components that must be met in order to report the code appropriately. These components are in addition to the medical necessity for performing the procedure(s). The frequency denial is correct because you would only be using this code once for this patient.

Vaida Posted Wed 19th of November, 2014 11:06:07 AM

Thank you for the answer! But what if the patient needs this procedure two days in a row? He gets admitted and discharged on one day and therefore we report 99235 with CPT 36522 and then everything is repeated the next day: patient is admitted, procedure performed and patient is discharged. Is there a code for subsequent visit? Sorry if the question sounds silly. I am just very unfamilliar with observation coding

SuperCoder Answered Wed 19th of November, 2014 11:24:04 AM

So you're saying that this patient was admitted and discharged on let's say, the 3rd and the patient went home and came back in on the 4th and was admitted and discharged all over again?

Vaida Posted Wed 19th of November, 2014 14:47:46 PM


SuperCoder Answered Fri 21st of November, 2014 16:48:18 PM

This scenario appears to warrant only the coding of the procedure. The doctor has scheduled or planned for the patient to receive these procedures in this order. This scenario seems to fit more as an outpatient procedure than observation. Be certain to verify with the hospital the patients status.

Vaida Posted Sat 22nd of November, 2014 09:55:17 AM

Thank you so much for clarifying this

SuperCoder Answered Mon 24th of November, 2014 08:01:05 AM

You are welcome.

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