Reader Question:
Inappropriate Edits
Published on Wed Nov 01, 2000
Question: Local carriers in our area have been bundling procedure codes 99213-25 and 31231. We have seen several patients in our office for nasal polyps and other separately identifiable diagnoses, such as hearing loss and cerumen impaction, and we have medical documentation to support these codes. How can I appeal this?
Laurie Seavey
Somersworth, N.H.
Answer: When billing 99213-25 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: an expanded problem-focused history and examination, and medical decision-making of low complexity -significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 31231 (nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]), both services should be linked to the appropriate diagnosis code, says Cindy McMahan, CPC, an otolaryngology coding and reimbursement specialist at SVA Consulting in Albany, Wis. Some carriers may require two separate diagnoses (i.e., the signs and symptoms that brought the patient in would be linked to the exam, whereas the final diagnosis should be linked to the procedure).
If there is sufficient documentation to cover the separate and identifiable evaluation and management (E/M) service, as indicated by the addition of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), the claim should be submitted for review with the documentation. Also, include the documentation for the 31231 procedure. If you have followed correct coding protocols and the claim is still denied, appeal the claim. Request also that a board certified otolaryngologist review your case.
A review of any contracts you have with insurance carriers also is recommended. Some carrier contracts may have special regulations regarding the performance of procedures and E/M services on the same day. Another problem that can occur is the failure of the carrier computer system to pick up modifier -25. This is usually found on the carrier explanation of benefits. A call to discuss this matter with the carrier will usually be sufficient to correct this problem.
Note: Because some payers prefer modifier -57 (decision for surgery) in place of modifier -25, even for minor surgery, check with your carrier before sending the claim.
