jmart81
New
We are currently having issues with Observation Consultations codes 99251-99255 being denied as POS code is incorrect. We are billing these codes to insurance companies that due accept consult codes. I code for Specialty providers who have been asked to consult on a patient that came in through the ER and was then transferred to Observation. My provider did not see the patient in the ER and the providers note state the referring provider.
When I have called on these claims, I have been told that we should be using 99221-99233. We are not the the provider who saw the patient in the ER or admitted the patient as observation. My providers are also not part of the same group or have the same specialty or subspecialty as the admitting provider.
They are saying that because the guidelines below states encounter in another site of service (ER) that in the guidelines for 99221-99223 it states
►When the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of service (eg, hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same date. In the case when the services in a separate site are reported and the initial inpatient or observation care service is a consultation service, do not report 99221, 99222, 99223, 99252,99253, 99254, 99255. The consultant reports the subsequent hospital inpatient or observation care codes 99231, 99232, 99233 for the second service on the same date. If a consultation is performed in anticipation of, or related to, an admission by another physician or other qualified health care professional, and then the same consultant performs an encounter once the patient is admitted by the other physician or other qualified health care professional ,report the consultant’s inpatient encounter with the appropriate subsequent care code (99231,99232, 99233). This instruction applies whether the consultation occurred on the date of the admission or a date previous to the admission. It also applies for consultations reported with any appropriate code (eg, office or other outpatient visit or office or other outpatient consultation).For a patient admitted and discharged from hospital inpatient or observation status on the same date, report 99234, 99235, 99236, as appropriate. For the purpose of reporting an initial hospital inpatient or observation care service, a transition from observation level to inpatient does not constitute a new stay.◄
When I have called on these claims, I have been told that we should be using 99221-99233. We are not the the provider who saw the patient in the ER or admitted the patient as observation. My providers are also not part of the same group or have the same specialty or subspecialty as the admitting provider.
They are saying that because the guidelines below states encounter in another site of service (ER) that in the guidelines for 99221-99223 it states
►When the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of service (eg, hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same date. In the case when the services in a separate site are reported and the initial inpatient or observation care service is a consultation service, do not report 99221, 99222, 99223, 99252,99253, 99254, 99255. The consultant reports the subsequent hospital inpatient or observation care codes 99231, 99232, 99233 for the second service on the same date. If a consultation is performed in anticipation of, or related to, an admission by another physician or other qualified health care professional, and then the same consultant performs an encounter once the patient is admitted by the other physician or other qualified health care professional ,report the consultant’s inpatient encounter with the appropriate subsequent care code (99231,99232, 99233). This instruction applies whether the consultation occurred on the date of the admission or a date previous to the admission. It also applies for consultations reported with any appropriate code (eg, office or other outpatient visit or office or other outpatient consultation).For a patient admitted and discharged from hospital inpatient or observation status on the same date, report 99234, 99235, 99236, as appropriate. For the purpose of reporting an initial hospital inpatient or observation care service, a transition from observation level to inpatient does not constitute a new stay.◄