Wiki Billing 99214 with 99396

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Davitto62

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Can 99396 be billed with 99214? Do I need to add modifier 25 to 99214? Patient is presenting for a physical as well as follow-up on multiple issues
 
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Generally, yes you would want to append Modifier 25 to the 99214, if the services provided include both preventive services and problem management services, and as long as documentation clearly supports both services. However, note that some insurances will not allow both a preventive visit and regular E/M visit on the same day, and have providers choose which service was the most prevalent.
 
Help

I am having issues with billing 99214 and a wellness visit. They don't want to pay for the well visit only the 99214. Does this have anything to do with RVU's? It is for Horizon blue cross blue shield. They pay the 99213 with the well visit. I am thinking it was an RVU issue but I am not sure.
 
In my experience, we have been paid when billing a 99213 (modifier 25) with a physical exam or Medicare Wellness exam. We don't bill higher than a 99213 when it's being billed with a preventive visit. We add the E/M code when patient presents with an acute problem on the day of their preventive visit or when they are in need of a follow up for a chronic problem.
Be sure your Dx pointers clearly define the reason for the addition of the E/M code.

Hope that helps.
 
help

Do you feel that the RVU's play a role in the 99214 being billed with 99396? because we get paid when we bill w/99213. I just really want to get to the bottom of this. I have done a ton of appeals and they are "upholding the original claim processing".
 
a level 4 visit with a preventive is a hard to justify visit. You must be able to have the components of a level 4 that are wholely and separately identifiable form the components of the preventive exam.. you cannot duplicate any part of it. Also a preventive with an office visit needs to reflect an abnormal finding simply addressing stable preexisting conditions does not justify billing a separate office encounter.
 
99213 and 99397

Hello All,

I'm a little confused as to why the Medicare Fee Schedule doesn't have a pricing for the 99397 but there is an an RVU for it. Providers have billed a 99213 and a 99397, Some pay some don't pay/reimburse for both codes. Can someone please help and explain why this is?
 
RosaGuth said:
Hello All,

I'm a little confused as to why the Medicare Fee Schedule doesn't have a pricing for the 99397 but there is an an RVU for it. Providers have billed a 99213 and a 99397, Some pay some don't pay/reimburse for both codes. Can someone please help and explain why this is?
Click to expand...

Medicare does have pricing for it but its suppressed from printing on the Medicare Physician Fee schedule. It's both status N not covered and has the not used for Medicare Pricing indicator this not reimbursable by Medicare. Many non covered medicare codes have RVU set because they may be covered by an MA plan for example. I use the RVU for commercial pricing. There is even RVU for Consultation Codes for example. Non covered service Acupuncture too. Over 140 codes fall under this concept, i attached a list of codes not accepted for Medicare which have RVU on the July file
 

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Modifier 25

The issue may be that the payer is rejecting the level 4 due to medically necessity standards included with the preventative which covers a comprehensive exam.
Your documentation will really have to be precise showing that the medical decision making was moderate/high for the exact diagnosis that the billing of 99214 is warranted.

Take a look and see if the documentation proves the issue is above and beyond a level 3 on top of the comprehensive exam included in the 99396.

Marissa Padworny CPC
Omaha NE.
 
CodingKing said:
Medicare does have pricing for it but its suppressed from printing on the Medicare Physician Fee schedule. It's both status N not covered and has the not used for Medicare Pricing indicator this not reimbursable by Medicare. Many non covered medicare codes have RVU set because they may be covered by an MA plan for example. I use the RVU for commercial pricing. There is even RVU for Consultation Codes for example. Non covered service Acupuncture too. Over 140 codes fall under this concept, i attached a list of codes not accepted for Medicare which have RVU on the July file
Click to expand...
And one other reason that this CPT code is not priced on the MPFS is that preventive services are billed using Level II HCPCS codes and not Level I CPT codes to Medicare.

https://www.cms.gov/Medicare/Preven...e-services/MPS-QuickReferenceChart-1.html#AWV

Hope that helps,
Karen
 
lorig1369@gmail.com said:
I am having issues with billing 99214 and a wellness visit. They don't want to pay for the well visit only the 99214. Does this have anything to do with RVU's? It is for Horizon blue cross blue shield. They pay the 99213 with the well visit. I am thinking it was an RVU issue but I am not sure.
Click to expand...

Insurances don't tend to pay or deny services based on "RVU" issues like this. If they allow a level 3 visit but not a level level 4 visit with a preventive visit, I would suggest that they doubt that the criteria is being met for both separately. So, they would want proof that the criteria was met for the preventive service (comprehensive service of age and gender appropriate history, exam, and counseling, guidance and interventions) and separately that 2 of the 3 key components of a detailed history, detailed exam and moderate complexity MDM are met for the new or preexisting problem that is addressed. If you have that, I would file an appeal for payment of both services.

Karen
 
and a flu shot

when I do 99214-25, 99396, and 90682 the ins is combining 99396 and 90682 what mod- do I use and where?
 
billing separate problem visit with preventive

Hello,
Coming into this late, but could anyone help me with whether or not we can use time spent in counseling/coc to base our level of office visit when billing a preventative as well?
Any feedback is appreciated.

Thank you so much!
 
I see no reason why you wouldn't be able to use time as your E/M code basis. However, just like if you are using hx, exam & MDM, that documentation of time must be SEPARATE from any time spent on the preventative. I won't say it's impossible, but it would certainly be an unusual circumstance that besides the preventative visit, the physician spent separate additional time in counseling/coc. In the original question, 99214 was billed with preventative. That requires 25 minutes face to face separate from the preventative visit with > 50% in counseling/coc. So, that would be quite a long visit. I don't think I've ever as a patient spent > 20-30 minutes with a physician for office visits.
 
Thank you for replying! I researched this after I sent the reply. I have read that the time would need to exceed the allotted time for the preventive, so I am glad you clarified that. I have providers that spend an additional 15 minutes in counseling or coc on separate issues from the preventative. In their documentation, they should describe in the history of the present illness all of the patient’s acute or chronic conditions and should detail in the assessment and plan how they managed them, making sure to show their extra cognitive work. This could include ordering or reviewing diagnostic tests, renewing prescriptions, making referrals, or implementing other changes to treatment. I read that neither CPT nor CMS requires a change in treatment to support billing for a second separate service.
Does this sound correct?
 
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