Primary Care Coding Alert

Question: A patient of ours was hospitalized for a urine infection. On the same day he was discharged, he also came to our office to be treated for anemia. When we tried to bill for the visit, we were denied because the procedure code/bill type was deemed inconsistent with the place of service, even though we had appended modifier 25 to the evaluation and management (E/M) visit. Is there any way we can get paid for this encounter?

Codify Subscriber

Answer: There could be several reasons for the denial. The first reason could be that your claim used the wrong place of service (POS) code. As the E/M service occurred at your provider’s office, make sure you use POS code 11 (Office) and not 21 (Inpatient hospital) on the claim.

Another reason could be that the anemia is related to the infection which, in turn, was the reason for the hospitalization. An office E/M service on the same day as a hospital discharge won’t get paid unless the condition your provider is treating in the E/M is unrelated to the discharge. This is because the hospital discharge codes — 99238 (Hospital discharge day management; 30 minutes or less) and 99239 (… more than 30 minutes) — include everything medically necessary for the patient to continue their recovery, rendering an additional E/M service related to the condition unnecessary. As noted in a parenthetical instruction following 99239 in CPT^®, “These codes are to be utilized to report all services provided to a patient on the date of discharge, if other than the initial date of inpatient status.”

Consistent with this understanding, the National Correct Coding Initiative (NCCI) has edits that prohibit payment for an office/outpatient E/M service for the same patient on the same date as either of the two hospital discharge day codes. Further, NCCI does not permit any modifier to override these edits. If the payer in question uses NCCI edits, that may explain the denial for the office visit.

If the office visit was truly unrelated to the hospital discharge and the reason for the patient’s hospitalization, then you may be able to appeal the denial on that basis with appropriate documentation. As always, you should check with your payer to confirm the reason for the denial and whether you can adjust the claim to enable reimbursement for your provider’s services.