Wiki 99215 Included in global fee of another procedure- what to do?

lemiserena

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I have a provider who bills 99215, 97112 and 90901 together, often with the same primary diagnosis. The E/M continues to not get paid as it is processing under global with other codes.
Appealing has not helped. Does the provider have to write this off or can we submit with lower E/M?
Lost!
Thank you!
 
The CCI edit is occurring between the 99215 and 90901.

Is there a significant, separately identifiable exam happening that day, or is the patient just coming in for scheduled biofeedback?

The edit does allow a modifier when appropriate, but whether or not you SHOULD use one depends on whether the documentation supports a distinct exam.
 
Hi Susan,

Thank you for your response. I am not a coder, but from what I can see from the charting patient is discussing their symptoms and the provider is using biofeedback as treatment of symptoms. I don't believe a separately identifiable exam is happening, the patient was having biofeedback and NMR regularly. Perhaps the provider should have used 99212 or 99213?
Would that make a difference? How/where do I learn more about CCI edits?
 
Hi Susan,

Thank you for your response. I am not a coder, but from what I can see from the charting patient is discussing their symptoms and the provider is using biofeedback as treatment of symptoms. I don't believe a separately identifiable exam is happening, the patient was having biofeedback and NMR regularly. Perhaps the provider should have used 99212 or 99213?
Would that make a difference? How/where do I learn more about CCI edits?

If there isn't a significant, separately identifiable exam, they shouldn't be billing any exam code at all. The level isn't the problem - all levels would hit the same CCI edit.

If the provider were performing a significant, separately identifiable exam, you'd use a Modifier 25 on the E/M code to signify that.

Important Note: Although your provider might say "just use the modifier then," I'd caution against routinely using Modifier 25 just to get things paid. It's on the Office of Inspector General (OIG) watch list, because it's considered the most abused modifier. Overusing it would throw up a HUGE audit red flag and likely come back to bite your provider in the butt eventually. (I suspect they likely don't want a fraud/abuse investigation from the government!) Use it only when the documentation supports a significant, separately identifiable exam, and you'll be fine.

You can read more about NCCI Edits on the CMS website: National Correct Coding Initiative Edits | CMS
 
If there isn't a significant, separately identifiable exam, they shouldn't be billing any exam code at all. The level isn't the problem - all levels would hit the same CCI edit.

If the provider were performing a significant, separately identifiable exam, you'd use a Modifier 25 on the E/M code to signify that.

Important Note: Although your provider might say "just use the modifier then," I'd caution against routinely using Modifier 25 just to get things paid. It's on the Office of Inspector General (OIG) watch list, because it's considered the most abused modifier. Overusing it would throw up a HUGE audit red flag and likely come back to bite your provider in the butt eventually. (I suspect they likely don't want a fraud/abuse investigation from the government!) Use it only when the documentation supports a significant, separately identifiable exam, and you'll be fine.

You can read more about NCCI Edits on the CMS website: National Correct Coding Initiative Edits | CMS
Thank you!
 
Is modifier 51 a better choice to show separate procedure performed same day by a dual licensed provider? For instance a naturopath who is also an acupuncturist? The charting shows separate identifiable procedure, and I have been using mod 25.
 
Is modifier 51 a better choice to show separate procedure performed same day by a dual licensed provider? For instance a naturopath who is also an acupuncturist? The charting shows separate identifiable procedure, and I have been using mod 25.

Modifier 51 is for multiple procedures. You'd never use a Modifier 51 on an E/M service. (Also, an E/M service is not a procedure.)

What code are you using the Modifier 25 on?
 
Forgot to add, the fact that the provider is dual licensed is irrelevant to proper coding of the service.
 
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