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Office visit claim has been deined due to same day discharge from the hospital

Fion Posted Wed 19th of September, 2018 09:32:22 AM
I have a denial claim for the patient. Patient was due to the urine infection problem admitted to the hospital on Mar 24th, 2018 and patient was discharged from the hospital on Mar 30, 2018, after the discharged from the hospital, patient come to our office to visited the PCP on the same day, patient needs the medication for the anemia. However, the claim has been denied by the insurance plan, the denial reason is:The procedure code/bill type is inconsistent with the place of service. There was another claim for this patient on the same day, because patient just discharged from the hospital, even thought, the office visit EM code had appended to the modifier 25, but still denied by the insurance. I would like to know if any way we can get paid on this situation?
SuperCoder Answered Thu 20th of September, 2018 09:30:38 AM


If the patient checks out of the hospital and then visits the physician's office on the same day, office E&M service won't get paid, unless the E/M is unrelated to the discharge. The presumption is that the discharge code includes taking care of all the patient's needs.

Also, claim denial may be due to incorrect usage of place of service. Please check the POS. For Inpatient, appropriate POS (place of service) code is 21 whereas for office visit, it would be 11. Verify for correct POS billed on HCFA form.  

If patient is coming for refill of medication for anemia and no E&M service is being performed, then this service will not get paid. If PCP performs complete evaluation and management service, unrelated to the discharge, then E&M service would be a billable service.


For further reference you can check the below article:



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