Wiki CO_B15 Denials on professional charges for Observation

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aarms

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Tompkinsville, KY
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Patient goes to the ER and ER doc admits and PCP comes in the next day to see them. We bill 99217, because the PCP didn't admit, but did see them the next day and discharge. We keep getting a denial, that the procedure requires a qualifying visit?
This is only happening on certain payers and the modifier 25 is not working either. Is there something I am doing wrong or does anyone know how to fix this issue?
 
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AmandaBriggs said:
Only the provider that ordered observation status can bill for observation services. Other providers should use the outpatient codes. See page 11 of this CMS article:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1875CP.pdf
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The hospital recently stopped using their billing company and had me start billing for the professional services done at the hospital so this is new to me and may seem like a silly question, just making sure I get this right.

The ER Dr bills his visit but doesn't bill any additional visits OR see the patient for the rest of the stay, the provider I bill for does. So are you saying I should bill office visit E&M codes on the day the provider discharges the patient?
If yes, do I bill the 99202-99215 CPT with the hospital as the location and POS 22 for observation?
 
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Yes, you would bill the office visit codes and use POS 22. Our facility discourages ER providers from admitting patients as they won't typically continue following the patient throughout their hospital stay,
 
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AmandaBriggs said:
Yes, you would bill the office visit codes and use POS 22. Our facility discourages ER providers from admitting patients as they won't typivally continue following the patient throughout their hospital stay,
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Ok that makes sense thank you for your help.
I am also wondering if the patient is admitted by ER scenario above and then 2 days later the PCP admits to In Patient status, does that mean the PCP is then able to bill for the "Inpatient" CPT Codes?
 
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aarms said:
Ok that makes sense thank you for your help.
I am also wondering if the patient is admitted by ER scenario above and then 2 days later the PCP admits to In Patient status, does that mean the PCP is then able to bill for the "Inpatient" CPT Codes?
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Any provider can bill using the "inpatient" CPT codes once the patient is admitted to "inpatient" status. Observation status is the only status with this weird rule.
 
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AmandaBriggs said:
Any provider can bill using the "inpatient" CPT codes once the patient is admitted to "inpatient" status. Observation status is the only status with this weird rule.
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Since 2023 CPT changes now combine the inpatient and observation codes do you know when or if the guidelines from the chapter you referenced will be changed? Just wondering if this outpatient CPT rule will change.
 
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aarms said:
Since 2023 CPT changes now combine the inpatient and observation codes do you know when or if the guidelines from the chapter you referenced will be changed? Just wondering if this outpatient CPT rule will change.
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I was wondering the same thing!
 
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