Wiki Billing a 99396 with a 99213 to Medicaid

[PPERDUE]

99396,24		Z0000
99213		R1084, I10, M79672, R718
	The allowed frequency of this service or procedure has been exceeded.
36415		Z0000
96127		Z0000

Is anyone able to provide any insight on how this claim should be submitted to Medicaid for reimbursement? The image above shows the claim as it was submitted however we received a denial from Medicaid with the following error code for the 99213.

• COB14: Only one visit or consultation per physician per day is covered.
• M86: Service denied because payment already made for same/similar procedure within set time frame

 

[SharonCollachi]

Well, it looks like they don't allow a well visit and a sick visit on the same day. But, further, why is there a modifier 24 on a well visit? 24 is unrelated E&M during op post period... or did you mean to put a different modifier?

 

[PPERDUE]

Our providers do their own billing and believes that the 24 modifier was the correct modifier as their understanding is that 99396 and the 99213 are both considered an office visit code. Would there be a more appropriate modifier that I should be alerting them to? I called Medicaid and was told that the denial could be due to their electronic claims system automatically denying claims with 2 E&M codes so I dropped it to paper and resubmitted the claim. The claim still denied with that error code. In speaking with Medicaid today they were going to have the claim reviewed to see why it is still denying. I was hoping that someone has experience with this situation who could advise on what we could have done to have this claim processed for reimbursement.

 

[SharonCollachi]

Modifier 24 is defined as an unrelated evaluation and management service by the same physician or other qualified health care professional (same specialty, same group practice) during a post-operative period. Clearly whoever taught the providers that 24 was the modifier to use to show two office visits on the same day is incorrect.

Here is one article that gives you guidance on doing a sick visit and a well visit on the same day, and the modifier to use. I would suggest if they are doing their own coding, including modifiers, they do more research and education.

 

[amygarrido]

Our providers do their own billing and believes that the 24 modifier was the correct modifier as their understanding is that 99396 and the 99213 are both considered an office visit code. Would there be a more appropriate modifier that I should be alerting them to? I called Medicaid and was told that the denial could be due to their electronic claims system automatically denying claims with 2 E&M codes so I dropped it to paper and resubmitted the claim. The claim still denied with that error code. In speaking with Medicaid today they were going to have the claim reviewed to see why it is still denying. I was hoping that someone has experience with this situation who could advise on what we could have done to have this claim processed for reimbursement.

Our office uses modifier 25...