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Wiki BCBS Refusal to pay E&M and Procedures

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mbcool

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San Lorenzo, NM
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I work for an Orthopedic group practice and we have been struggling with our Local BCBS plan for the last 2 years and the problem is getting worse. not better. Our hospital E&Ms won't be paid with or without a 57 modifier on the same day a major procedure (of any kind) is done. And in the last year, in the clinic, if our coders miss adding a 25 modifier on the day of a minor procedure (for two completely different problems) BCBS will not acknowledge the 25 modifier and will never pay the E&M. We have exhausted every level of appeal/redetermination they have. Is anyone else having this problem with BCBS of MN or any BCBS? Any Feed back would be helpful. Thanks
 
BSDE procedure

We are having a similiar problem getting our E & M codes and our Clinical Treatment Planning codes to pay on the same date. As a matter of fact, BSDE has made a Radiation Therapy payment policy instructing to pay only one or the other on the same date. CCI edits allows both procedures on the same date. I have went through my provider representative who was no help. I have requested a peer (our physician) to peer( their contracting clinician) review to discuss this issue since it is a patient care issue.
 
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