tci ED Coding & Reimbursement Alert - 2013 Issue 8

Reader Question: All Observation Codes Require At Least A Detailed History

Question: We just received a denial for a moderate level observation care service (99235), and I cannot figure out why. The denial states that the service and the code choice do not match. Any idea what we might have done wrong? Idaho Subscriber Answer: It might have to do with your history and exam levels. In order to report even the lowest level observation code (99234), CPT® requires that the physician must: perform a detailed or comprehensive observation history; and perform a detailed or comprehensive examination. Example: According to the CMS documentation guidelines, a “comprehensive” observation history means...

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