Wiki Consultaion in Observation

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clopez

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Hello,

Upon a review I came across a Cardiologist who submitted a claim with a 99214 with POS 11 for a consult that was requested by the Dr. who admitted the patient to Observation status. Which I know to be incorrect. However do not know the proper code to bill.

What code should the Cardiology report for his consult to a patient in observation status on same day of admit or on the subsequent day?

Please Help Me and provide CMS guidelines if possible.

Thank you :confused:
 
if pt is in observation status, you MUST bill POS 23. You cannot use a POS on a claim just to simply ensure that your claim is going to get paid.
 
Place of service code 23 is emergency room. According to the Medicare Benefit Policy Manual, chapter 6 Section 20.6, subsection B "When a physician orders that a patient receive observation care, the patient's status is that of an outpatient." This would make the POS 22, not 23.
 
CMS contradicts AMA Observation Consult Codes

clopez said:
Doreen,

Thank you very much for your help! This is exactly what I needed. Yes I agree POS is 22.:D
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I just want to add a word of caution; Don't bill an Obs Admit code for a consultation because only the admitting doctor can bill 99217-99220.

In reviewing the CPT Book "New or Established Patient Initial Hospital Observation Care Services 99218-99220
The following codes are used to report the encounter(s) by the supervising physician or other qualified health care professional with the patient when designated as "observation status." This refers to the initiation of observation status, supervision of the care plan for observation and performance of periodic reassessments. For observation encounters by other physicians, see office or other outpatient consultation codes (99241-99245) or subsequent observation care codes (99224-99226) as appropriate."

This contradicts CMS guidelines: "In the event another physician evaluation is necessary, the physician who provides the additional evaluation bills the office or other outpatient visit codes when they provide services to the patient.
For example, if an internist orders observation services, furnishes the initial evaluation, and asks another physician to additionally evaluate the patient, only the internist may bill the initial observation care code. The other physician who evaluates the patient must bill the new or established patient office or other outpatient visit codes as appropriate."

For Medicare patients only 99201-99215 can be billed by a Consultatant but for other plans that do not allow consultation codes, subsequent observation care codes 99224-99226 are appropriate.
 
Michigan Medicaid plans do not pay for subsequent observation codes 99224 99225 99226 so we code them as outpatient/office 9921X...
 
Consultation in hospital observation

For Medicare - If cardiologist perform consultant (refer by attending physician) - can we bill 99218-99220 (for commercial and medicare) or 99201-99205/99211-99215 (for medicare)? Which one is appropriate?
 
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prirs1985 said:
For Medicare - If cardiologist perform consultant (refer by attending physician) - can we bill 99218-99220 (for commercial and medicare) or 99201-99205/99211-99215 (for medicare)? Which one is appropriate?
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99218-99220 are outpatient hospital observation codes and not consultation codes, 99201-5/99211-5 are outpatient office New/Established Patient visits. To answer your question, the Place Of Service would depend on which code you can use. If outpatient hospital (POS 21) and documentation supports an Observation code, then 99218-99220 could be appropriate. If in the office (POS 11) and for Medicare (which does not accept Consultation codes) 99201-5/99211-5 would be more appropriate.

Hope that helps!
 
Per CPT guidelines, 99218-99220 are to be used only by the supervising physician in the initiation of observation status and not by other physicians.
 
Pathos said:
99218-99220 are outpatient hospital observation codes and not consultation codes, 99201-5/99211-5 are outpatient office New/Established Patient visits. To answer your question, the Place Of Service would depend on which code you can use. If outpatient hospital (POS 21) and documentation supports an Observation code, then 99218-99220 could be appropriate. If in the office (POS 11) and for Medicare (which does not accept Consultation codes) 99201-5/99211-5 would be more appropriate.

Hope that helps!
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Thank you for your respond. Can we still use 99241-99245 for commercial in office consultation?
 
prirs1985 said:
Thank you for your respond. Can we still use 99241-99245 for commercial in office consultation?
Click to expand...

Some insurances still pay for outpatient office consultation codes, however I would still check with your payer policy in order to avoid a denial.
 
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