Wiki 99285 denied as inclusive to 99223/57

[kt_rhodes@yahoo.com]

Scenario:

A patient comes into the ER and diagnosis ends up being acute appendicitis. The ED doctor bills for a 99285. The patient is then admitted by a hospitalist with 99223/57 on the same day of service. The same hospitalist performs the procedure with a 90 day global period.

My problem:
I've noticed a trend where BC/BS is denying the 99285 as being inclusive to the major procedure. This is in NY. Anyone have any ideas why a 99285 would be denied as inclusive?

 

[jimbo1231]

Shouldn't Deny

There is no basis for the B/S denial. The ED visit is a different place of service and an entirely different service tham the admit and appendectomy. The ER visit preceeded the procedure and doesn't realte to the global period. This one should defintely be appealed with documentation and maybe the ED visit page from the CPT.
Did I read write that the Hospitalist did the appendectomy? Haven't seen that one before.

Jim