Observation and Inpatient (E/M) Common Denials and Resolutions - JF Part B

Observation and Inpatient (E/M) Common Denials and Resolutions

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

Search for a Code

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

Last Updated Fri, 28 Sep 2018 15:49:48 +0000

Jurisdiction F - Medicare Part B

Observation and Inpatient (E/M) Common Denials and Resolutions - JF Part B

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