tci ED Coding & Reimbursement Alert - 2006 Issue 8

Reader Questions: Include Detailed History for Observation Codes

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 on the claim?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 2006 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...

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