Wiki Observation E&M CPT denials

[landv]

I have had a few denials from a payor for CPT 99219 and 99225. The payor requests the MR as a prepay audit and the E&M is not being paid. The reason for the denial is "Not Supported. The submitted medical records do not indicate that patient was an observation status. Therefore, the billed observation E&M cannot be supported. Of note, there are more appropriate CPT codes for established office or outpatient visit E&M Services.

My provider is a General Surgeon so usually I am billing 99219 as the doctor's H&P prior to surgery with Modifier 57 with a Surgical code on line 2 of the claim.
I have went as far as printing the documentation from the hospital where it shows the patient was "Observation Status" and they will still deny the CPT. Has anyone had this issue?

Can anyone tell me what type of "Documentation" needs to be included in the Medical Record for documentation?

Thanks!

 

[mitchellde]

To bill observation codes the provider must write an order in the patient chart to admit to observation. If the patient is presenting to the facility for a scheduled surgery then you cannot bill an E&M with the 57 modifier as the surgery was previously decided. The observation of the patient post surgery is inclusive to the procedure and not billable. Only if there is some extenuating issue for the patient to need additional observation and the provider writes the order to admit observation can the observation be coded be considered, however it will depend on the circumstances as to whether it is considered global.

 

[liloe517]

I work for general surgeons that do ER call. When one of my surgeons sees a patient that is in OBS status I bill either a 99203-99205 or 99243-99245 depending on insurance. I only bill the 99219 if my Dr admitted to observation. I have used the 99225 for follow up visits for patients under OBS status but if surgery is done same day or next they are usually bundled with the surgery.