Wiki ALABAMA WORKERS COMPENSATION - MODIFIER QUESTION

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7
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SLOCOMB, AL
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I am having problems getting claims paid where an injection is given in addition to an office visit. Either the OV pays or the admin fee pays. I am billing, for instance, 99203 - 25, J0702, and 96372. Do I need to add a modifier to the admin fee (96372)?
 
In WC the application of modifiers is useful to give the payer an idea of what you are intending to bill; however, there are no automated edits that give you a pass when these are billed. Typically the combination of the office visit and the 96372 will be flagged for review, OR the 96372 will be automatically disallowed, which is more likely without the mod-25. A reviewer would expect to see in your chart notes or report, a justification for the billing of the 96372 in addition to the OV. If your report says... "patient returns for injection of..." then the OV would be disallowed. This is especially true if your practice does this all the time. You need to document all the other details of the examination and its rationale as the primary activity for the visit. I would be interested to know which reason codes are used for the denials, to see if they are using 1) a prior state dispute ruling, 2) some other guideline such as ODG, or 3) the "documentation doesn't support the level of service billed..." approach.
 
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