Below provides a processing overview for observation and inpatient evaluation and management (E/M) claims billed after an already processed observation or inpatient E/M claim. To view options for the provider, find your denied CPT code in bold below, and review the options based on the other previously processed code.
Key Points
- Deciding factor is provider's specialty and not provider's group affiliation
- First claim received, first to pay
- Sub-specialties are non-factor for all scenarios
- Providers should review with the other provider(s) caring for the patient to ensure proper billing. Most denials occur when an inpatient E/M is billed after an outpatient E/M and vice versa. The first E/M sets the precedence for the claims that follow.
- Example:
- 1st provider billed and approved for CPT 99218 (Outpatient)
- 2nd provider bills CPT 99232 (Inpatient) the following day and will deny
Inpatient Admittance (99221-99223)
E/M in History | Denial and/or Provider Resolution |
99221-99223; 99231-99239 | - May reimburse if different specialty or same specialty/different diagnosis is billed
- Deny if same specialty/same diagnosis is billed. Provider may submit an appeal
|
99217, 99218-99220, 99224-99226 | - Deny if billed on same day
|
99234 - 99236 | - Will deny; Provider must prove an admit/discharge/admit on same day situation
|
Inpatient Subsequent Visit (99231-99233)
E/M in History | Denial and/or Provider Resolution |
99221-99223; 99231-99239 | - Reimburse if different specialty or same specialty/different diagnosis is billed
- Deny if same specialty/same diagnosis is billed. Provider may submit an appeal
|
99218-99220 | - Deny if billed on same day
|
99217, 99224-99226, 99234-99236 | - Deny if billed on same day
|
Inpatient Discharge (99238-99239)
Note: Only one 99238-99239 is allowed per stay
E/M in History | Denial and/or Provider Resolution |
99221-99223; 99231-99239 | - Reimburse if different specialty or same specialty/different diagnosis is billed
- Deny if same specialty/same diagnosis is billed. Provider may submit an appeal.
|
99217, 99224-99226 | - Deny if billed on same day
|
99218-99220 | - Deny if billed on same day. Provider must prove an observation admit occurred after patient was discharged. Provider may submit an appeal request
|
99234-99236 | - Will deny; Provider must prove a discharge/admit/discharge on same day situation. Provider may submit an appeal request
|
99238-99239 | - Deny if billed on same/consecutive days or no admit in-between two discharges
|
Outpatient/Observation Discharge (99217)
E/M in History | Denial and/or Provider Resolution |
99221-99223 | - Reimburse if billed day before
- Will deny if billed on same or next day
|
99224-99226 | - Reimburse if different specialty or same specialty/different diagnosis is billed
- Deny if same specialty/same diagnosis is billed
|
99231-99233, 99238-99239, 99218-99220 | - Deny if billed on same day
|
99234-99236 | - Will deny; Provider must prove an admit/discharge/admit on same day situation. Provider may submit an appeal request to prove an admit/discharge/admit on same day situation
|
Outpatient/Observation (99218-99220)
Note: 99218-99220 can only be approved the day before an admit 99221-99223 without the presence of a 99217
E/M in History | Denial and/or Provider Resolution |
99218-99220 | - Reimburse if different specialty or same specialty/different diagnosis is billed
- Deny if same specialty/same diagnosis is billed. Provider may submit an appeal request
|
99221-99223 | - Deny if billed on same or next day
|
99224-99226 | - Reimburse if different specialty or same specialty/different diagnosis is billed
- Deny if same specialty/same diagnosis is billed
|
99217 | - Deny if billed on same day
|
99231-99233 | - Deny if date of service (DOS) billed is prior to/on same/or after 99231-99233 DOS
|
99234-99236 | - Will deny; Provider must prove an admit/discharge/admit on same day situation. Provider may submit an appeal request
|
99238-99239 | - Will deny; Provider must prove patient was admitted to outpatient/observation after inpatient discharge. Provider may submit an appeal request
|
Outpatient/Observation Subsequent Visit (99224-99226)
E/M in History | Denial and/or Provider Resolution |
99221-99223 | - Reimburse if billed day before
- Deny if billed same or next day
|
99217-99220, 99224-99226 | - Reimburse if different specialty or same specialty/different diagnosis is billed
|
99231-99233 | - Deny if DOS is billed is prior to/on same/or after to 99231-99233 DOS
|
99234-99236 | - Will deny; Provider must prove a discharge/admit/discharge on same day situation. Provider may submit an appeal request
|
99238-99239 | - Will deny; Provider must prove patient was admitted to outpatient/observation after inpatient discharge. Provider may submit an appeal request
|
Admittance/Discharge on Same Day (99234-99236)
E/M in History | Denial and/or Provider Resolution |
99217-99239 | - Will deny; Provider must prove an admit/discharge/admit on same day situation. Provider may submit an appeal request
|
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