Problems with E/M and Physical on same day

[dboutwell]

I am having problems with billing when a patient comes in for a physical and the visit turns into a sick visit. Example 99396 and 99214. I have never used a modifier when billing these codes. Now United Healthcare is denying my 99214 stating it needs a modifier. I sent a corrected claim with a 25 modifier and they denied that for incorrect modifier. Does anyone have any input.
Thanks.

[btadlock1]

Originally Posted by dboutwell

I am having problems with billing when a patient comes in for a physical and the visit turns into a sick visit. Example 99396 and 99214. I have never used a modifier when billing these codes. Now United Healthcare is denying my 99214 stating it needs a modifier. I sent a corrected claim with a 25 modifier and they denied that for incorrect modifier. Does anyone have any input.
Thanks.

The denial is wrong - appeal with records. When you bill a preventive and sick E/M on the same day, the 25 modifier goes on the sick visit. See preventive service CPT guidelines (page 34 of AMA's professional edition), and if necessary, include a copy of that page with your appeal.

I'd try calling UHC and asking them to reprocess it, first, though. You'll probably get the denial overturned, without having to send in a formal appeal. Hope that helps!

[btadlock1]

Here's their policy on it:
https://www.unitedhealthcareonline.c...cies/PMED_Prev Med_2012B.htm

"Overview

Preventive Medicine services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, UnitedHealthcare will reimburse the Preventive Medicine service plus 50% of the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed."

[dboutwell]

Thank you so much for your help and the information. I will definantly send this to an appeal but will probably be denied because fo the 90 day processing rule.

[btadlock1]

Originally Posted by dboutwell

Thank you so much for your help and the information. I will definantly send this to an appeal but will probably be denied because fo the 90 day processing rule.

You have 90 days from the date of the last EOB, to appeal - not 90 days from the DOS. I'd strongly recommend calling them first - they're pretty good about fixing that kind of stuff over the phone. Good luck!

[SUESCERT]

Make sure you have the mod 25 on the office visit not the cpe