Billing/Coding Question.....

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When a patient has a PE and gets a separately identifiable E/M service on the same visit, we code the PE and code the E/M service, ie: 99213 and add modifier 25. Medicare will reimburse for both, however, our office has run into problems with BCBS paying the E/M service and wanting us to write off the PE. Are we reporting/coding these correctly? We appreciate any feedback from you guys. I am a brand new CPC, and a novice with billing :) Thanks so much!
 

pamsbill

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When a patient has a PE and gets a separately identifiable E/M service on the same visit, we code the PE and code the E/M service, ie: 99213 and add modifier 25. Medicare will reimburse for both, however, our office has run into problems with BCBS paying the E/M service and wanting us to write off the PE. Are we reporting/coding these correctly? We appreciate any feedback from you guys. I am a brand new CPC, and a novice with billing :) Thanks so much!

If a PE is a physical exam, as opposed to a pulmonary embolism, then you should appeal for payment for both. To be successful in your appeal, the documentation should be able to stand separately for each of the 2 separate services. If you look at the documentation for the 99213, it needs to meet the criteria for a 99213 all by itself. It is best to have the providers keep the documentation of the 2 services separate. It makes it easier to appeal.
 
Messages
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If a PE is a physical exam, as opposed to a pulmonary embolism, then you should appeal for payment for both. To be successful in your appeal, the documentation should be able to stand separately for each of the 2 separate services. If you look at the documentation for the 99213, it needs to meet the criteria for a 99213 all by itself. It is best to have the providers keep the documentation of the 2 services separate. It makes it easier to appeal.

Thanks so much for the feedback!
I appreciate the advice on the documentation for an appeal.
 

mitchellde

True Blue
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You cannot bill the Z00.00 with a symptom code, and you cannot bill the Z00.01 with a symptom code. The only time you can bill a preventive encounter with an office visit is when your provider documents an abnormal finding in an otherwise asymptomatic patient. Then you use the Z00.01 plus the abnormal finding and the preventive visit code plus the office level code with the 25 modifier. Then if you need to appeal you must show the office visit components for the abnormality and the preventive co phones for the preventive encounter without using any element twice.
 
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