Unlisted E/M service code 99499 is for Initial Hospital and other evaluation and management services.
Section 30.6.1 "Selection of Level of Evaluation and Management Service" is in the Medicare claims processing manual.
When a service does not reflect a CPT code description, it must be reported as an unlisted service with the code 99499.The claim must include a description of the service.When the service doesn't meet the full terms of a code description, the carrier can value it.
The minimum requirements of the lowest level of code in a code family are typically reflected in an E/M service.Providers are instructed to select the highest-level service within a Category or Subcategory of E/M codes for which all criteria are met.A lower level code must be selected if all the criteria are not met.Only in the rare circumstance where the visit does not reflect the lowest level of E/M service in an applicable CPT code family can the service be used.Supporting documentation is needed to help determine a payment amount.
It is not possible to interpolate between two levels of E/M service within a category or subcategory.The appropriate choice is the next lower code for which all criteria are met.
One or more days after a patient's placement in hospital observation status, it is true that the CMS, Publication 100-04, Medicare Claims Processing Manual, Section 12, 30.6.8 states.
The physician must bill an initial hospital visit for the services provided on the day the patient is admitted to the hospital.
At the time of this transfer, the service must still comply with medical necessity and documentation requirements.In order, the following apply.
The level of service is appropriate if the initial hospital care is called an "inpatient admission" as they are not technically admit codes.
If the criteria for "inpatient admission" is not met, then a service was necessary, and all the required components performed and appropriately documented meet criteria.
If an E/M service is necessary, performed and documented that does not meet the criteria for CPT 99231, then the service may be paid.
It is the responsibility of the provider to ensure that all necessary information has been documented in the medical record in a rare circumstance where the only conclusion that is appropriate is CPT 99499.Medical necessity and reasonableness standards must be met by the service.A brief statement explaining why another E /M code does not apply is included in the documentation.
A concise description of the type of service is required."office/other outpatient visit" and "hospital admission" are examples of descriptions.
Documentation should not be sent with the claim.After the claim has been received, Noridian will send a letter requesting documentation.
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