Otolaryngology Coding Alert

2 field-tested tips for breaking E/M bundles

If you use modifier -25 correctly on office visit test claims and insurers still deny the service, use marked-up notes and request a meeting with the medical director to appeal the rejections.

Some payers that use ClaimCheck bundling software, such as United Healthcare, are incorrectly including E/M services (such as 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) with audiology test 92551 (Screening test, pure tone, air only), says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. To get paid properly for your otolaryngologist's services, you must scrutinize rejections and appeal, appeal, appeal. Otherwise, the insurers will take advantage of the edits, she says.
 
To improve your E/M pay, follow two pointers: 1. Highlight Separately Identifiable Points If the E/M falls under the billable modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) guidelines, and the payer bundles the service, you should appeal the denial, says Rhonda Buckholtz, CPC, practice manager at Crawford and Fitch Ear, Nose and Throat in Franklin, Pa. Include a copy of the notes and your separate audiologic test. Keep your appeal letter short and sweet (KISS). "Highlight what you want to stand out in your notes to draw the payer's attention to your point," she says.

To appeal scenario 1 or 3, Cobuzzi says to emphasize these areas:
 
The otolaryngologist ordered 92551 based on the MDM that she performed during the significant, separately identifiable E/M service. (Include notes that show this. For instance, a note that states "Based on evaluation of child's impaired speech, I decided to order a screening test" clearly shows the office visit's separate nature.)
 
A different provider, the audiologist, performed the audiology.
 
The otolaryngologist provided a significant, separately identifiable E/M service from the small pre- and postoperative E/M work associated with the test, which is why you are identifying the separate service with modifier -25. 2. Involve Higher-Ups If payers continue to stick to the bundle, request a meeting with the medical director. Show the representative that when an otolaryngologist sees a patient for an E/M service and based on that evaluation orders 92551, you can bill the procedures and providers separately.