Avoid Denials for Procedures and E/M Services Performed the Same Day
Published on Sun Aug 01, 1999
Otolaryngology practices often report denials for claims arising from office procedures performed the same day as an evaluation and management (E/M) visit. For example, David Hendrick, MD, an otolaryngologist with Colorado Mountain Medical P.C., in Vail, CO, says he receives frequent denials for claims involving nasal endoscopy (31231, nasal endoscopy, diagnostic, unilateral or bilateral) and fiberoptic laryngoscopy (31575, laryngoscopy, flexible fiberoptic; diagnostic) performed in his office.
The denials may be for the procedure itself, as in the case of Dr. Hendrick, or for the E/M that accompanied it, depending on the carrier, the geographic location of the practice, and the complexity of the procedure and/or E/M.
Generally, denials for office procedures performed on the same day as an E/M service occur for one of three reasons, says Edward Babb, MD, CPC, an otolaryngologist in private practice in Lafayette, NJ, who also is a member of Physician Advocate Consultants and Trainers (PACT), a company which educates physicians on administrative matters.
1. Inappropriate use of modifier -25. This modifier describes a significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service. Properly used, modifier -25 identifies a significant E/M service that is done in addition to the procedure performed.
2. Failure to satisfy medical necessity requirements. Procedures must be appropriate treatment for the patients diagnosis. If a procedure is inappropriate, unrecognized or inconsistent with the diagnosis of the injury or illness being treated, it will not be reimbursed. In coding terms, this means ICD-9 codes must correspond with CPT codes.
3. Unbundling. The Health Care Financing Administration (HCFA) set up the global system with rules and guidelines to ensure standardized reimbursement for the same services across the country. The Medicare-approved amount for surgery covered by a global package includes payment for somebut not allservices related to the surgery when furnished by the physician who performs the surgery or by members of the same group within the same specialty. Any care or procedure listed in the package that is performed during the global period0 or 10 days for minor procedures, 90 days for major surgerycannot be claimed separately. Postoperative periods also apply to some procedures that may not be considered surgical.
The global surgical package takes into account the time, effort and services rendered for procedures that are bundled together. Payment is made for the entire package, not for each individual service provided.
Inappropriate coding combinationsbetter known as unbundlingoccur when attempts are made to bill for individual services that are covered by single comprehensive codes. Take, for example, 31231 (nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) and 31254 (nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]). According to HCFA guidelines on global procedures, [...]
