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Steer Clear of Mistaken Procedure Coding

Bearing in mind the "where and when"guidelines will keep your observation claims on track for payment but avoiding certain roadblocks will speed the process and reduce confusion and denials.
Roadblock #1: You have all the necessary documentation, but you've put the tests and the observation service on different claims.You didn't get paid for the observation service.
Solution: Bill all the diagnostic information on the same claim form as the observation.
Roadblock #2: On the day before or the day of observation, you've coded a procedure with a "T" status indicator. The claim for separate observation payment was denied.
Solution: Unless the procedure you coded was Q0081 (Infusion therapy, using other than chemotherapeutic drugs,per visit), a "T" status indicator in an observation claim means the service is already included.
Roadblock #3: In a claim for multiple observation periods with the same diagnosis, you coded one set of diagnostic procedures for the all the observation services.You got the claim back.
Solution: Multiple observation periods for the same diagnosis require multiple sets of procedures. Use only one set of tests for multiple observation services when the services are for different diagnoses.
Roadblock #4: Your claim documents the required diagnostic tests, which the provider performed on the second day of observation. It gets denied.
Solution: Submit a claim for separate observation payment only when the diagnostic procedures are done on the dates of the E/M or critical care visit or within the first 24 hours of observation.
 

- Published on 2003-04-01