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.

Modifiers with Unlisted Codes

Question:

Can I use modifiers on an unlisted code?

Answer:

In some circumstances, a modifier may be appropriately appended to an unlisted code. 

For example,  

• CPT says, while uncommon, if multiple separately reportable unlisted codes are performed on the same patient on the same date by the same physician, multiple unlisted codes may be reported. If the two procedures are performed in the same anatomic region, then multiple units of the unlisted code may be reported with a modifier 59 

• Modifier 62 (two surgeons/co-surgery) may also be appended to an unlisted code such as 64999 if co-surgery is documented.  

• Modifier 58 for staged or more extensive procedures may also be appended to alert the payor to a second surgery during the global period, 

• During the global period, it may also be appropriate (and recommended) to append global period modifiers such as 78 or 79 to an unlisted code to fully describe the surgical scenario to a payor. 

Do not append modifier 50 (bilateral procedure), modifier 51 or modifier 52 or 53 to an unlisted code. Your base, or comparison code, should reflect modifier 50 and the associated increase in fee. The same is true for modifier 22 

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

Coding Laparoscopic Liver Biopsy

Question:

How is a laparoscopic biopsy of the liver reported. Can we use code 47001, Biopsy of liver?

Answer:

47001 Biopsy of liver, needle; when done for indicated purpose at time of other major procedure (List separately in addition to code for primary procedure) may only be reported with an open procedure. See CPT Assistant 1992 below. If a laparoscopic biopsy of the liver is performed at the same time as another laparoscopic procedure, for example a laparoscopic cholecystectomy, report an unlisted code (47379). There is no CPT code for a laparoscopic liver biopsy.

*This response is based on the best information available as of 2/1/24.

Cholecystotomy Procedure

Question:

How should you code an open cholecystotomy, with a drain placement and a biopsy of the gallbladder wall is performed. Can the biopsy of the gallbladder be separately reported?

Answer:

No, the biopsy of the gallbladder wall is not separately reportable this is bundled and inclusive to the cholectstotomy. The correct code to report for this procedure would be CPT 47480,Cholecystotomy or cholecystostomy, open, with exploration, drainage, or removal of calculus (separate procedure).

*This response is based on the best information available as of 12/14/23.

Appendectomy with Cecum Resection

Question:

As part of an appendectomy, a portion of the cecum was involved and was included in the resection.. Can this be reported as a cecectomy?

Answer:

No, that resection is considered part of the appendectomy procedure and not separately reported.

*This response is based on the best information available as of 11/30/23.

POEM Procedure Coding Part 2

Question:

I know the POEM procedure, is reported with code 43497,Lower esophageal myotomy, transoral (ie,perioral) endoscopic myotomy (POEM).One of our surgeon does the G-POEM procedure. This is a gastric peroral endoscopic myotomy (G-POEM) how is this reported?

Answer:

There is no current CPT code for this procedure. Report with an unlisted code, 43999,Unlisted procedure, stomach.

*This response is based on the best information available as of 11/2/23.