Cite November 1999 Federal Register to Bolster Modifier -25 Audiology Claims
Published on Mon Jan 01, 2001
Even though audiology tests now bundle evaluation and management (E/M) services, both should be paid as long as documentation supports the significant, separately identifiable nature of the E/M and modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day as another procedure or service) is appended.
HCFAs national Correct Coding Initiative (CCI) version 6.3 bundled E/M services to many diagnostic services, including all audiology tests. The edits were designed to prevent physicians from separately billing for the routine examinations performed before such services. The edits all include a 1 indicator, however, which means an appropriate modifier will override the edit and the local Medicare carrier should reimburse the physician for both services.
But otolaryngology practices in several regions across the country report that since the edits were announced, payment for the E/M service is being denied, even when a significant, separately identifiable E/M service is documented and billed with modifier -25 attached.
Despite HCFAs stated intent that carriers should publish the edits (and, presumably, the guidelines for the correct use of modifier -25) in their bulletins before the edits were implemented, this does not seem to have occurred in some jurisdictions.
Essentially, carrier responses can be placed in one of four categories:
1. Outright refusal to pay for the E/M service, regardless of modifiers, or insinuation that modifier -25 claims will be closely monitored;
2. Denial unless modifier -59 (distinct procedural service) is used;
3. Denial with modifier -25 unless two separate diagnoses are provided for the E/M and the audiology test(s); or
4. Payment for both services if modifier -25 is appended to the E/M service.
Appeal Denied Claims
Any response other than the last is inappropriate and should be vigorously appealed to the highest level, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a physician billing firm in Lakewood, N.J.
This is not a matter of opinion or carrier discretion, Cobuzzi says, noting that local Medicare carriers are mandated to observe CCI edits. Unfortunately, she notes, when CCI published the edits, additional information was not provided on why the edits were made or how to override them.
That information can be found in the Nov. 2, 1999, Federal Register, which clearly states that edits would be introduced to prevent pretest evaluations already included in the test from being billed separately. The same item also instructs physicians to use modifier -25 to indicate that a significant, separately identifiable E/M service was provided on the same day as the test.
When appropriate E/M services are denied because the carrier considers them bundled into the audiology tests, Cobuzzi recommends that otolaryngologists include in their [...]
