Wiki Billing 96372 and receiving inclusive denials

[madsmacpc]

I work for an Oncology office and it was brought to my attention we are adjusting off a lot of our injection admin codes . Someone in our office had stated that in another office they worked for they added a 59 mod on ALL admin codes and never had any denials. I don't see where the 59 mod would be necessary on EVERY admin code .

I am starting to see a trend where we will see a patient for an office visit and a proper 25 mod is applied to the E/M service . We also bill for the admin code and the drugs. Will these always deny if we bill an office visit regardless of the 25 mod?

I'm also told these still deny inclusive to the drug itself without an E/M code??

Anyone else have issues with the dreaded admin codes denying ?

This also applies to the 90686 and 90471

 

[erjones147]

Is it a specific insurance that's denying due to policy?

I never have any trouble with (for example):

99213-25
90686
90471
96372
J3420

I have never had an admin code deny as long as mod 25 is properly applied

I agree with you to not just be slapping a 59 onto everything

 

[1formissy]

If you are billing an admin code with an E/M service, the modifier 25 on the E/M code would be the bundling modifier for the admin code. I see too many claims (I am an auditor) where the E/M code has a 25 modifier, and the admin code has a 59 modifier. This is inappropriate billing and can potentially trigger a audit from the payer. CMS frowns upon using the 59 modifier so "loosely."
If an office is billing the 59 modifier on the admin code, and getting payments, beware. Like Medicare, they pay now, and ask later. That's why Medicare has RAC audits. There is no way CMS can pre-audit every 4.4 million Part B claims they get daily, so if a claim has an overriding edit modifier, the system will allow payment. The the RAC auditors come along, and recoup the payment.
What I communicate to the providers during my education sessions is, the admin code can be reported with an E/M code, so as long as it is significantly separate and identifiable. I ask them to append the Chief Complaint diagnosis code to the E/M, and the diagnosis to the admin code.
For example:


99213-25 DX code M25.562
96372 DX code M94.262

Although the modifier 25 is not diagnosis driven, it does provide the examiner a clear description of why that admin code is considered separate from the E/M service.