Denials for Initial Hospital Care and Observation E/M Codes: 2024

Question:

We are experiencing denials when we bill 99221-99223 and the place of service is observation (outpatient hospital).  Are we doing something wrong?

Answer:

You are billing correctly based on CPT 2023 guidelines for E/M that merged inpatient hospital encounters/codes with observation encounters/codes.  Unfortunately, some payor claims processing systems may not yet recognize these changes as they apply to billing.  You will have to appeal these denied claims, with CPT references showing the current guidelines for E/M reporting.  

*This response is based on the best information available as of 2/29/24.

DME Billing Inquiry

Question:

Do you have any tips on how to handle Medicare Replacement/Part C/Advantage patients for possible non-coverage?

Answer:

Medicare Advantage Plans are required to cover what Medicare covers at a minimum. You should reach out to the individual plan and inform them of this. You can also attach the Medicare coverage policy when you appeal the claim.

*This response is based on the best information available as of 2/15/24.

Seborrheic Keratosis

Question:

What diagnosis code would I use to report a seborrheic keratosis? 

Answer:

Seborrheic Keratoses are benign lesions. The typical diagnosis is L82.1 (other seborrheic keratosis) but if inflamed the correct diagnosis is L82.0 (inflamed seborrheic keratosis).

*This response is based on the best information available as of 2/15/24.

APRN Billing Inquiry

Question:

We have an APRN joining our practice, can you please confirm which pain management procedures they are allowed to perform.  Are they allowed to perform all procedures except RFA procedures?

Answer:

The answer to your question will depend on the NP scope of practice for your state so you will need to research this information for your state.  In addition, check provider qualification requirements with your commercial payors and your MAC. The LCDs for Facet Joint Injections Epidural Steroid Injections, and Nerve Blocks for Chronic Pain and Neuropathy list the provider qualifications.

*This response is based on the best information available as of 2/15/24.

Denials for Initial Hospital Care and Observation E/M Codes: 2024

Question:

We are experiencing denials when we bill 99221-99223 and the place of service is observation (outpatient hospital).  Are we doing something wrong?

Answer:

You are billing correctly based on CPT 2023 guidelines for E/M that merged inpatient hospital encounters/codes with observation encounters/codes.  Unfortunately, some payor claims processing systems may not yet recognize these changes as they apply to billing.  You will have to appeal these denied claims, with CPT references showing the current guidelines for E/M reporting. 

*This response is based on the best information available as of 2/15/24.

Billing Ultrasound Guidance with Cranial Tumors

Question:

My surgeon uses ultrasound to facilitate locating lesions in the brain and wants to bill 76998-26 for imaging. Is this appropriate? 

Answer:

No, ultrasound to locate a lesion and/or to confirm adequate resection is included in n the primary procedure and not separately billed 

*This response is based on the best information available as of 2/15/24.