Wiki 64450 Bundling with E/m

[sam.anderson@curemd.com]

Hi, I am receiving bundling denial from Humana PPO plan when billing E/m code 99212 with Injection(s), anesthetic agent Code 64450. Can someone help me understand why insurance is bundling the E/m code with 64450 even there is no coding conflict?

 

[sls314]

Hi, I am receiving bundling denial from Humana PPO plan when billing E/m code 99212 with Injection(s), anesthetic agent Code 64450. Can someone help me understand why insurance is bundling the E/m code with 64450 even there is no coding conflict?

There is an NCCI edit between 64450 and the E/M charge.

If there was a significant and separately identifiable E/M service performed that day, you would need to use a Modifier 25 on your E/M charge to indicate that.

 

[ollielooya]

Hi, I am receiving bundling denial from Humana PPO plan when billing E/m code 99212 with Injection(s), anesthetic agent Code 64450. Can someone help me understand why insurance is bundling the E/m code with 64450 even there is no coding conflict?

I'm curious as to whether modifier 25 would be appropriate in this situation. Was the patient evaluated at a previous visit and returning for the injection? If so, all that would be billable would be the injection(s} procedure for this particular visit. However, if this was an initial visit and it was determined that the procedure would be done, then modifier 25 would be applicable for the EM.

 

[amyjph]

I'm curious as to whether modifier 25 would be appropriate in this situation. Was the patient evaluated at a previous visit and returning for the injection? If so, all that would be billable would be the injection(s} procedure for this particular visit. However, if this was an initial visit and it was determined that the procedure would be done, then modifier 25 would be applicable for the EM.

Agree. Why is there a level 2 office visit being reported with this in the first place? Highly unusual for them to make the decision at a low level office visit and do the injection on the same date. I suppose it's not completely out of the question, but highly unusual.

This would be a suspicious billing pattern aside from the missing 25 which the payer edit stopped, it would probably be subject to further review even if it had the 25.