Wiki Outpatient Services

[medicalsec]

I am suddenly having problems with Molina and Vantage Insurance companies in California when the patient is classified as observation. If we admit to observation we use CPT 99217-99220 with a place of service of 22, and we also use 22 if the patient is taken to the operating room for surgery. If we are not the physician admitting and are asked to do a consultation then we use the outpatient consult codes or the new patient codes if consults are not accepted by the insurance company, and then of course the insurance companies thinks that we are seeing these patients unauthorized because we are using what they refer to as (office codes) These insurance companies are indicating that we should use place of service 23 for the surgery and the consult. Often when we consult it is after the patient has left the ER and has been placed in a room.

I explained that we are not doing a cholecystectomy or an appendectomy in the ER. I have done several appeals on these cases, and I when I speak to the representatives they still insist that all of the place of services have to be 23 because the patient came in through the ER, and it should be based on the fact that they were not admitted to inpatient. I have never had a problem in the past with coding this type of situation, and have even sent then coding materials to justify the coding.

Please advise if you have any suggestions, differences of opinion, or have had a similar issue with these insurance companies.

Thanks,

Dee