Wiki Add-On E/M codes needing modifiers

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lillianivy

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We just recently had a claim denied from Human stating that the prolonged visit add-on cpt code 99354 needed modifier 25 as well as the main E/M cpt code 99215 when a procedure is performed on the same DOS.

It was understood to me that add-on codes do not need a modifier bc it is billed with the primary code that will have the modifier. When I put the codes into SuperCoder NCCI edit checker it does not say that a modifier is needed for 99354, only 99215. So to me it is confirming my thoughts.

HELP!!!

These are the codes I used:
99215.25
99354
96365
J1100x10

Thank you,

Lydia
 
Yes. They claim that 99354 and 96365 cannot be billed together without a modifier. I've pulled up all information I can find and nothing supports there claim. They insist that 99354 needs a modifier 25 just like 99215. I'm willing to jump through there hoops but it doesn't make sense. Also, if it's incorrect I do not want to start billing incorrectly.
 
OK, never mind - I don't think this will get paid. I just did a "clear claim" and this is what it said:

Click on recommendation of "Disallow" or "Review" to obtain clinical edit clarification.
Line Procedure Description Mod 1 Mod 2 Mod 3 Date of Service Place of Service Pay Percent Recommend
1 99215 OFFICE/OUTPATIENT VISIT EST 25 9/12/2013 11
(Office) 0 Allow

2 99354 PROLONGED SERVICE OFFICE 9/12/2013 11
(Office) 0 Disallow

3 96365 THER/PROPH/DIAG IV INF INIT 59 9/12/2013 11
(Office) 0 Allow


Why is procedure 99354 disallowed when submitted with procedure 96365?

Procedure Description

99354 PROLONGED SERVICE IN THE OFFICE OR OTHER OUTPATIENT SETTING REQUIRING DIRECT PATIENT CONTACT BEYOND THE USUAL SERVICE; FIRST HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR OFFICE OR OTHER OUTPATIENT EVALUATION AND MANAGEMENT SERVICE)

96365 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR

Response:
When a substantial diagnostic or therapeutic procedure is performed, the evaluation and management service is included in the global surgical period as defined by CMS.- Procedures that are assigned a 90-day global surgery period are designated as major surgical procedures; those assigned a 10-day or 0-day global surgery period are designated as minor surgical procedures.- Evaluation and management services, submitted with major surgical procedures, (1-day) pre-operatively, on the same date of service, or during the 90-day postoperative period, are not recommended for separate reporting because they are part of the global service.- Evaluation and management services, submitted with minor surgical procedures, on the same date of service or during the 10-day post-operative period, are not recommended for separate reporting because they are part of the global service.- Evaluation and management services, submitted for "established" patients with minor surgical procedures (0-day), are not recommended for separate reporting on the same date of service because they are part of the global service and because there is an inherent evaluation and management service component included in all surgical procedures.Procedures that are assigned a global period of MMM, XXX, YYY, or ZZZ are audited as follows:- Evaluation and management services, submitted with maternity procedures (MMM), during the antepartum period (270 days), on the same date of service, or during the postpartum period (45 days) are not recommended for separate reporting if the procedure includes antepartum and/or postpartum care.- Evaluation and management services, submitted with XXX anesthesia procedures, 1-day pre-operatively, on the same date of service, or 1-day postoperatively, are not recommended for separate reporting because they are part of the global anesthesia service.- Evaluation and management services, submitted with XXX (excluding anesthesia procedures) or YYY procedures on the same date of service are not recommended for separate reporting if it is determined that the procedure includes an inherent evaluation and management component.- Evaluation and management services, submitted with add-on procedures (ZZZ), are not recommended for separate reporting if the parent procedure includes an inherent evaluation and management component.This rationale does not take into consideration the use of modifiers that may or may not affect the outcome of the claim.


Therefore, procedure 99354 is not recommended for separate reimbursement when submitted with procedure 96365.
 
Where did you do this "Clear Claim"? Is that from Humana? I use SuperCoder.com(which we pay for) and it claims it follows the NCCI/CCI. I used their version of the NCCI/CCI edit checker and it states NO CCI/NCCI edit. So am I to assume this is not a good resource for all insurances?
 
In the land of neither, nor

It has been my experience that insurances, while following the NCCI edits and general guidelines for coding, also have a tendency to also implement their own interpretations regarding modifier usage.

As coders who work in billing offices, we live in a world of somewhere in between that of the coding world and of the billing world. As coders, we are taught the basic coding conventions and guidelines allowing us to build a foundation of knowledge from which we can continue to grow and learn. Once out in the real world, we find not everyone follows the same rules as we were taught in school. We cry fowl and insist we are right-after all we are certified coders are we not?! Some are aghast at the payers boldness in telling US how to code our claims shouting accusatory statements riddled with judgement, expectations, and disgust. "Who do they think they are telling us coders how to apply those modifiers" or "How dare they, they're not even following even the most basic coding rules! Everyone knows what they are after all!" Then there are those who internalize this process and begin to doubt themselves, their skills, and even the tools they use to help them perform their coding duties.

Here's perhaps the most important thing I've learned as a coder: If what the insurance company is asking you to do doesn't misrepresent a patient's diagnosis or the services provided to h/her, there is no harm or fowl in placing a modifier on or removing a modifier from a particular CPT code because a payer suggested you do so. It is not a matter about who is right and who is wrong. It is a matter of interpretation. Their reasoning may not make a bit of sense from a coding perspective
So I, as well a many of you, must learn to live in a world somewhere in between the coding world and billing world. As individuals we can best serve our profession in recognizing and accepting this location-straddling two worlds at once-in which we find ourselves.
 
What was the prolonged E/M service performed versus the infusion? You wouldn't get both if "they" occurred simultaneously. If not, would need to re-address. Or maybe I missed the documentation information.
 
rryder1963 said:
It has been my experience that insurances, while following the NCCI edits and general guidelines for coding, also have a tendency to also implement their own interpretations regarding modifier usage.

As coders who work in billing offices, we live in a world of somewhere in between that of the coding world and of the billing world. As coders, we are taught the basic coding conventions and guidelines allowing us to build a foundation of knowledge from which we can continue to grow and learn. Once out in the real world, we find not everyone follows the same rules as we were taught in school. We cry fowl and insist we are right-after all we are certified coders are we not?! Some are aghast at the payers boldness in telling US how to code our claims shouting accusatory statements riddled with judgement, expectations, and disgust. "Who do they think they are telling us coders how to apply those modifiers" or "How dare they, they're not even following even the most basic coding rules! Everyone knows what they are after all!" Then there are those who internalize this process and begin to doubt themselves, their skills, and even the tools they use to help them perform their coding duties.

Here's perhaps the most important thing I've learned as a coder: If what the insurance company is asking you to do doesn't misrepresent a patient's diagnosis or the services provided to h/her, there is no harm or fowl in placing a modifier on or removing a modifier from a particular CPT code because a payer suggested you do so. It is not a matter about who is right and who is wrong. It is a matter of interpretation. Their reasoning may not make a bit of sense from a coding perspective
So I, as well a many of you, must learn to live in a world somewhere in between the coding world and billing world. As individuals we can best serve our profession in recognizing and accepting this location-straddling two worlds at once-in which we find ourselves.
Click to expand...

Sooo very well-said!!! :D
 
rryder1963 said:
It has been my experience that insurances, while following the NCCI edits and general guidelines for coding, also have a tendency to also implement their own interpretations regarding modifier usage.

As coders who work in billing offices, we live in a world of somewhere in between that of the coding world and of the billing world. As coders, we are taught the basic coding conventions and guidelines allowing us to build a foundation of knowledge from which we can continue to grow and learn. Once out in the real world, we find not everyone follows the same rules as we were taught in school. We cry fowl and insist we are right-after all we are certified coders are we not?! Some are aghast at the payers boldness in telling US how to code our claims shouting accusatory statements riddled with judgement, expectations, and disgust. "Who do they think they are telling us coders how to apply those modifiers" or "How dare they, they're not even following even the most basic coding rules! Everyone knows what they are after all!" Then there are those who internalize this process and begin to doubt themselves, their skills, and even the tools they use to help them perform their coding duties.

Here's perhaps the most important thing I've learned as a coder: If what the insurance company is asking you to do doesn't misrepresent a patient's diagnosis or the services provided to h/her, there is no harm or fowl in placing a modifier on or removing a modifier from a particular CPT code because a payer suggested you do so. It is not a matter about who is right and who is wrong. It is a matter of interpretation. Their reasoning may not make a bit of sense from a coding perspective
So I, as well a many of you, must learn to live in a world somewhere in between the coding world and billing world. As individuals we can best serve our profession in recognizing and accepting this location-straddling two worlds at once-in which we find ourselves.
Click to expand...

I agree completely, Jeannie. Nicely worded.

Along these same lines, I find that some of my payers want 25 modifiers on critical care codes 99291 and 99292 when billed together, which is silly and redundant. My guess is when the payers were writing the 25 modifier rule logic for their software scrubbers, they didn't make an exception for 99292. Like you said, as long as the essence of the coding accurately reflects the documentation, I just roll with it.
 
rryder1963 said:
It has been my experience that insurances, while following the NCCI edits and general guidelines for coding, also have a tendency to also implement their own interpretations regarding modifier usage.

As coders who work in billing offices, we live in a world of somewhere in between that of the coding world and of the billing world. As coders, we are taught the basic coding conventions and guidelines allowing us to build a foundation of knowledge from which we can continue to grow and learn. Once out in the real world, we find not everyone follows the same rules as we were taught in school. We cry fowl and insist we are right-after all we are certified coders are we not?! Some are aghast at the payers boldness in telling US how to code our claims shouting accusatory statements riddled with judgement, expectations, and disgust. "Who do they think they are telling us coders how to apply those modifiers" or "How dare they, they're not even following even the most basic coding rules! Everyone knows what they are after all!" Then there are those who internalize this process and begin to doubt themselves, their skills, and even the tools they use to help them perform their coding duties.

Here's perhaps the most important thing I've learned as a coder: If what the insurance company is asking you to do doesn't misrepresent a patient's diagnosis or the services provided to h/her, there is no harm or fowl in placing a modifier on or removing a modifier from a particular CPT code because a payer suggested you do so. It is not a matter about who is right and who is wrong. It is a matter of interpretation. Their reasoning may not make a bit of sense from a coding perspective
So I, as well a many of you, must learn to live in a world somewhere in between the coding world and billing world. As individuals we can best serve our profession in recognizing and accepting this location-straddling two worlds at once-in which we find ourselves.
Click to expand...

Well said!!!

Thank you!
 
rryder1963 said:
It has been my experience that insurances, while following the NCCI edits and general guidelines for coding, also have a tendency to also implement their own interpretations regarding modifier usage.

As coders who work in billing offices, we live in a world of somewhere in between that of the coding world and of the billing world. As coders, we are taught the basic coding conventions and guidelines allowing us to build a foundation of knowledge from which we can continue to grow and learn. Once out in the real world, we find not everyone follows the same rules as we were taught in school. We cry fowl and insist we are right-after all we are certified coders are we not?! Some are aghast at the payers boldness in telling US how to code our claims shouting accusatory statements riddled with judgement, expectations, and disgust. "Who do they think they are telling us coders how to apply those modifiers" or "How dare they, they're not even following even the most basic coding rules! Everyone knows what they are after all!" Then there are those who internalize this process and begin to doubt themselves, their skills, and even the tools they use to help them perform their coding duties.

Here's perhaps the most important thing I've learned as a coder: If what the insurance company is asking you to do doesn't misrepresent a patient's diagnosis or the services provided to h/her, there is no harm or fowl in placing a modifier on or removing a modifier from a particular CPT code because a payer suggested you do so. It is not a matter about who is right and who is wrong. It is a matter of interpretation. Their reasoning may not make a bit of sense from a coding perspective
So I, as well a many of you, must learn to live in a world somewhere in between the coding world and billing world. As individuals we can best serve our profession in recognizing and accepting this location-straddling two worlds at once-in which we find ourselves.
Click to expand...

I'd agree with this.
Generally, I tend to code as I have learned to code...and when a specific insurance company tells me they want something coded a specific way - in order for them to pay - as long as it does not misrepresent the patient's diagnosis or the doctor's treatment, I just plain flat do it for that one claim and move on...continuing to code as I have always done on all future claims - unless I get the same situation with the same insurance company.

It can be daunting to keep a ton of notes about what each different insurance company wants, so, if you can't keep up with them, don't sweat it, code as you normally would, and make corrections when requested by insurance companies to get your doctor paid - as long as such changes do not misrepresent the diagnosis or the treatment performed.

I tend to keep a little online notebook with tabs for each insurance company, and I add to it whenever I learn something new about a specific insurance company's procedures. I happened across the program back when I was a transcriptionist - it is called Little Red Notebook. I have found it can be used for our purposes too. The program costs $19.95 to buy, but there's a free version, too...with fewer available tabs - the developer is Horus Development. The free version should probably provide you with enough tabs to document your different insurance company's quirks. I think the free version gives you five tabs, the paid version gives you 100.

Hope that helps! It's good if you can have some quick-reference notes available about certain insurance company's quirks, so that when you run across the situation again, you can do accordingly. Anything that can expedite the processing on a claim is a good thing, from our perspective...so long as it does not compromise the integrity of what we are doing (by, for example, misrepresenting services rendered or diagnoses made)

This is a similar situation with doctors. Some doctors call for things which technically should not go together, but, in the end, we are not doctors and cannot diagnose. I have one doctor who ROUTINELY codes 401.9 with 796.2 - even though the definition of 796.2 precludes 401.9 - however, if the doctor diagnoses it - I am going to code it. Never had a claim rejected or pended for having 401.9 and 796.2 - but it is not technically correct coding to have both.
 
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ABridgman said:
I'd agree with this.
Generally, I tend to code as I have learned to code...and when a specific insurance company tells me they want something coded a specific way - in order for them to pay - as long as it does not misrepresent the patient's diagnosis or the doctor's treatment, I just plain flat do it for that one claim and move on...continuing to code as I have always done on all future claims - unless I get the same situation with the same insurance company.

It can be daunting to keep a ton of notes about what each different insurance company wants, so, if you can't keep up with them, don't sweat it, code as you normally would, and make corrections when requested by insurance companies to get your doctor paid - as long as such changes do not misrepresent the diagnosis or the treatment performed.

I tend to keep a little online notebook with tabs for each insurance company, and I add to it whenever I learn something new about a specific insurance company's procedures. I happened across the program back when I was a transcriptionist - it is called Little Red Notebook. I have found it can be used for our purposes too. The program costs $19.95 to buy, but there's a free version, too...with fewer available tabs - the developer is Horus Development. The free version should probably provide you with enough tabs to document your different insurance company's quirks. I think the free version gives you five tabs, the paid version gives you 100.

Hope that helps! It's good if you can have some quick-reference notes available about certain insurance company's quirks, so that when you run across the situation again, you can do accordingly. Anything that can expedite the processing on a claim is a good thing, from our perspective...so long as it does not compromise the integrity of what we are doing (by, for example, misrepresenting services rendered or diagnoses made)

This is a similar situation with doctors. Some doctors call for things which technically should not go together, but, in the end, we are not doctors and cannot diagnose. I have one doctor who ROUTINELY codes 401.9 with 796.2 - even though the definition of 796.2 precludes 401.9 - however, if the doctor diagnoses it - I am going to code it. Never had a claim rejected or pended for having 401.9 and 796.2 - but it is not technically correct coding to have both.
Click to expand...
I have to disagree in a big way!!! You should NEVER code anything just to get paid, or just because the provider listed it that way. Coding is a much more responsible profession than that. If the payer has you append modifiers that are incorrect then don't do it! First of all a payer is not allowed to tell you how to bill a specific claim. They can set coverage determinations and policy per your contract. But that in no way tells you how to complete a claim, only how they will pay a specific instance. When a provider appends diagnostic codes to a document, we do not have to use those codes, we code based on the documentation and apply the coding guidelines. And it is non compliant to code 401.9 with 795.2. And just because you have been paid does not mean it was coded correctly.
If we are to keep the integrity of the coding profession high then we must adhere to high standards. To just do whatever cheapens us and relegates us back to being data entry clerks!!
 
You misunderstood what I said.
I said IF IT DOES NOT MISREPRESENT THE DIAGNOSIS OR THE SERVICE RENDERED.

Maybe you want to fight with an insurance company. I, myself, have never run into this particular situation, except once. And it was an application of the 25 Modifier which I felt was not justified.

But Medicare would not pay without it. So I appended the Modifier and moved on.

In this particular situation:

I had a patient we normally see for dialysis, which is billed on a once-a-month code, 90960.

This same patient was seen in the hospital - by my doctor, during the same month we had billed the 90960 - but for different dates, and for totally unrelated things.

Medicare bundled the hospital visits with the once-a-month 90960 dialysis code, and thus refused to pay the hospital followups - 99233. They refused it for "same day of service."

But it WASN'T the same day of service. And the two incidents were totally unrelated. As such, I did not feel a 25 Modifier was justified.

However, this is what Medicare wanted, and it was easier than fighting with them and telling them I was right and expecting to change their minds. The 25 Modifier did not misrepresent the service rendered, the patient STILL DID get a 90960 and two 99233's - and the same amount was billed as would otherwise have been.

The diagnosis codes were correct. Nothing was misrepresented. But, because Medicare wants to be stupid, and bundle a once-a-month code with other codes...so that they don't have to pay for service actually rendered...and adding a 25 Modifier gets them to pay it...then I'm adding the Modifier, because IT DOES NOT MISREPRESENT THE ACTUAL SERVICE RENDERED.

If you'd like to take up that fight with Medicare you're welcome to, I'm not about to.
Good luck getting them to change their minds - let me know how that works out for you, okay?

I am NOT SUGGESTING that you code something just to get paid. I AM suggesting that sometimes it is easier to go along to get along - AS LONG AS NOTHING IS ACTUALLY MISREPRESENTED.

Incidentally - in this case - the 25 Modifier was appended to the 99233's. You can't even append a 25 Modifier to 90960. Being as it is a once-a-month code, probably every billing software out there would flag a 25 Modifier on such a code.
 
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