Persistence and Payer
Published on Sat May 01, 1999
It happens often enough in pediatrics: A child comes in for a well visit, and turns out to be sick. The pediatrician performs the well visit, and thenin additiontreats the problem. But in order to get paid for both preventive care services (99381-99385, 99391-99395) and an office visit, you need to put a modifier -25 on the office-visit code. This tells the insurance company that yes, you are billing for two E/M services on the same day, but the reason is that you provided two separate services.
This modifier is supposed to be CPTs built-in mechanism for ensuring that a physician will get paid for the extra work involved in seeing a patient twice on the same day, without having the patient return for a separate visit at another time. Unfortunately, insurance companies dont always recognize modifiers. They see the two E/M codes, and either deny one and pay the other, or bundle them into one code and pay their contractually agreed upon fee for that one code.
Appeal, Appeal, Appeal
We talked to one office manager who, after a year of persistence, has succeeded in getting most modifier -25 claims paid. We appeal them left and right, and thats how weve succeeded, says Marion Hayes, office manager for Shapiro and Bernstein, a three-pediatrician, one-nurse practitioner practice in Silver Spring, MD.
Most pediatricians make the mistake of giving up after the first denial, says Hayes. Or they see a pattern of denials and throw up their hands in dismay, saying its too much trouble. The insurance companies know all about the modifier -25, Hayes comments. If you say nothing, its to their advantage. But if you fight it, then you have a chance.
Hayes began her modifier -25 battle with the insurance companies a year ago, when the practice first started using it. We could have given up then, because everything was getting rejected, Hayes reports. But she persisted. First of all, she noticed that the EOBs came back one of two ways: either denied or bundled.
If its denied, that means we have to educate the insurance company about the meaning of the modifier -25, she says. We tell them to read the CPT book, she states. We have a photocopy of CPT Codes , and we send it to them, she adds. And we talk to them about it.
Another problem is bundling. The insurance company takes the preventive-medicine services code (like 99393) and adds the office-visit code (such as 99313) to it. For example, the pediatricians claim is for $78 for the [...]
