Article Detail - JF Part B

For the month of May there was a large number of appeals for CPT 99232.

CPT 99232 - Subsequent hospital inpatient or observation care, per day, for evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of decision making.

When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. Below are some of the most common denial reasons from the appeals we received:

• Partially furnished by another provider
• Verify with other providers treating patient who should bill
• Attachment or documentation required for adjudication were missing.
• Charge exceeds fee schedule or legislated fee amount - This is an information message telling you the amount you billed is more than the Medicare Physician Fee Schedule is allowed to pay by law.
  • There are usually no appeal rights attached with this message. The remainder is an amount you would write off, based on your agreement with Medicare to accept their payment as payment in full.
• Benefit for this service is included in the payment for another provider.
  • CMS does not reimburse a subsequent hospital visit in addition to hospital discharge day management service on the same day by the same physician.
• Payment adjusted because payer deems information submitted does not support this many, or frequency of services.

Resource

• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12 - Physician and Non-physician Practitioners
• Observation and Inpatient (E/M) Common Denials and Resolutions