Wiki billing 93000 with e/m

[temarye]

I work in family practice where providers will do an EKG on pts because of rapid heart beats, palpitations, etc. im being denied by most insurance companies. do I have to put a mod 59 on this for payment. I understand that mod 59 usage is looked down on. can anyone assists me. thank you in advance.th

 

[danskangel313]

I work in family practice where providers will do an EKG on pts because of rapid heart beats, palpitations, etc. im being denied by most insurance companies. do I have to put a mod 59 on this for payment. I understand that mod 59 usage is looked down on. can anyone assists me. thank you in advance.th

What types of denials are you receiving? Are you billing the ECGs with a medically necessary complaint/symptom/problem/condition diagnosis? Payers will typically deny if the service is done as a screening or routine procedure, or if the diagnosis does not meet the definition of medically necessary.

A 59 modifier would not be appropriate. You could apply a 25 mod on the E/M charge IF the encounter meets the definition "significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure." The documentation would have to support this; the provider would need to document the E/M portion of the encounter and separately document for the interpretation and report for the ECG.

 

[tcan618]

I work in family practice where providers will do an EKG on pts because of rapid heart beats, palpitations, etc. im being denied by most insurance companies. do I have to put a mod 59 on this for payment. I understand that mod 59 usage is looked down on. can anyone assists me. thank you in advance.th

We have NGS as our Medicare provider and if we are billing an AWV with a medical E/M and an EKG on the same day, Medicare requires the 59 modifier on the EKG and a 25 modifier on the medical E/M, however if billing only an E/M and EKG a modifier is not required from any of our payers.

 

[danskangel313]

The bundling is between the office visit and the AWV, not the EKG.

When billing a problem visit on the same day as an AWV, you would add a 25 mod to the E/M charge. It's important to remember that whatever work was done for the AWV should NOT also be counted into the E/M when you level it (such as a portion of the history or exam).

When billing, for example, you would have G0439, 99212-25, and 93000.

When it comes to adding a 59 to 93000, I'm not sure why that would be necessary; there are no bundling edits there. I highly question that because this is a MAC and they SHOULD be following the NCCI edits. Personally, I would ask for documentation from NGS explaining the reason they are not adhering to the edits before I start throwing around unnecessary modifiers, especially a 59.

And it would be correct when billing only an E/M with 93000 that no modifier would be needed.

 

[temarye]

Thank you so much for the information you shared.