What Is Wrong?

[willlen]

I am billing Medicare for Doctor of Osteopathy (DO) using 2 codes: E/M code99213 with modifier 25 and code 98926 - osteopathic manipulation. For many years we got payment for both codes. Suddenly, week ago I got payment only for code 98926 and zero for code 99213 wich was bundled with code 98926. What happened? And what can I do?
Thanks.

[dmaec]

Appeal it if you have supporting documentation. If you can show that the E/M is "significant separate identifiable". You should be able bill it with the .25 modifier along with the 98926.

[member7]

I agree. You should appeal it. Maybe the carrier put some edits in place that kicked out your claims in error.

[thompsonsyl]

Hi,

I can't seem to log on to the CCI Edits webpage but have you looked your codes up there?

If your second code is considered a component of the e/m code, it will require that you append a -59 modifier.

Hope this helps!

[dpage77]

Modifier -25 indicates that a separately identifiable E/M
service was performed on the same day as another independent procedure
or service by the same physician. When a code from the special services,
procedures and reports section is reported with an E/M service, Modifier
-25 should not be appended to the E/M service, as the codes from the
99000-99091 series do not describe separately identifiable services, but
rather adjunctive services or circumstances that further describe the
basic service rendered."

[willlen]

Thanks for all the feedback.
Thank you, Sylvia for your reply. I know in the CCI Edits code (98926) is a component of the E/M code 99213. But does it require exactly modifier -59 or some modifier, in particular mod. -25? Now the issue of appending 59 vs 25 has come up. I think modifier -25 is more appropriate to use in this situation than a mod -59? I use mod. -25 with the code 99213 for many years and did not have any problems until now. OK, I will resubmit a claim with mod. -59 and will see what happen.

[Lisa Bledsoe]

Just out of curiosity, did your Medicare carrier recently change? We have had a tremendous amount of problems since our carrier changed.

[ruhood]

Look at the narrative in the CPT book above the section that contains code 98926. It indicates that mod. 25 should be used on the E/M service. I would point to that in my appeal.

[thompsonsyl]

Hi,

Willen....cpt narrative does state that a same dos e/m would require a (-25) modifier. The only caveat I see is that in order to "unbundle" procedures (CCI), modifier (-59) is typically what is used on the "component code". I'm curious to see how your claim will process. Let us know!

[OliviaPrice]

I just wanted to comment of the use of modifier -25 vs -59. Modifier -25 is used on E/M codes to seperate it from a procedure. Modifier -59 is used on procedure codes to seperate it from another procedure code. You should never append modifier -59 to an E/M code.