Wiki Observation/Inpatient Codes for 2023?

[apash3399]

Hello fellow coders,

I need some assistance with the new E&M changes to the OBS/Inpatient codes..

Medicare rejected a claim for codes 99285(ER) and 99223(OBS/Inpt). Getting an CCI conflict edit where codes 99285 and 99223 'code pair that is not allowed by NCCI even if an appropriate modifier is present.'

Recording to the CPT guidelines we can be these codes with a modifier 25 to separate the E&Ms.

Is there something I am missing in the new guidelines? Anyone else having the same problem with Medicare?

 

[thomas7331]

Under Medicare policy a provider can only bill one E&M service per day. The only exception that they'll allow is when the patient returned on the same day for a completely unrelated problem. So if these two were billed by the same provider as part of the same encounter, then you'll need to combine the two services into a single E&M code.

 

[apash3399]

Under Medicare policy a provider can only bill one E&M service per day. The only exception that they'll allow is when the patient returned on the same day for a completely unrelated problem. So if these two were billed by the same provider as part of the same encounter, then you'll need to combine the two services into a single E&M code.

This patient saw two different providers. patient came the ER saw ER provider then patient got admitted OBS then saw hospitalist who was different provider.

I never had this error before until the new E&M changes.

 

[thomas7331]

This patient saw two different providers. patient came the ER saw ER provider then patient got admitted OBS then saw hospitalist who was different provider.

I never had this error before until the new E&M changes.

In that case (and assuming these providers are of two different specialties) you have coded and billed correctly, and no modifier should be necessary. I would speak to someone at Medicare because there cannot be CCI edits between services of different providers with different specialties.

 

[BrendaAS]

Hello. I'm having the same problem. Patient sees the emergency room doctor and then is admitted to observation by the hospitalist. Medicare is denying the e/m for the emergency room - two different providers two different specialties. The biller has contacted Medicare and all the rep says is that we need a modifier. We've tried 25 but still getting denials for the emergency room doctor. Anyone else running into this?