Wiki billing e&m and iv pushes

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daah cpc

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Hi, I work for a urgent care/ family practice clinic and we are having trouble getting an iv push and an e&m paid on the same visit in our urgent care.

Example....

a patient comes in with gastroenteritis and the doctor orders zofran and morphine. we bill a 99213 with a 25 modifier and than a 96374 and a 96375 for the drugs..

the insurance company is denying payment on the office visit.. everywhere I look it says to append the 25 modifier which I have.


any help would be greatly appreciated....

thanks in advance for your advice....:confused:
 
is the IV push a scheduled event? If so, you will not be paid. If not, does the patient present with symptoms or a definitive diagnosis of gastroenteritis? If signs and symptoms, use that diagnosis on the visit, the definitive diganosis of gastroenteritis on the IV push IF the doctor has documented the exam and the diagnosis. You may also just have a problem with the insurance carrier - some carriers (i.e. Geisinger) usually do not pay both office visit and procedure.
 
I also work for an Urgent Care and we bill 96374 with an E/M all the time. It is completely appropriate if you append the mod 25 on the E/M. Diagnosis differential has nothing to do with it. In a setting such as Urgent Care where services are rendered on a urgent and walk in basis, these procedures would never be scheduled. The physicians' decision to perform these procedures in this setting are made after history, examination, labs, x-rays, etc. are performed. The decision to perform the IV push arises from the E/M service, thus the modifier 25. You are 100% correctly billing these and should most definately appeal with your carriers.
:)
 
I agree..I did urgent care billing for several years. The IV pushes should be paid, in addition to the office visit with mod 25. I would definitely appeal.
 
dee ostrosky said:
is the IV push a scheduled event? If so, you will not be paid. If not, does the patient present with symptoms or a definitive diagnosis of gastroenteritis? If signs and symptoms, use that diagnosis on the visit, the definitive diganosis of gastroenteritis on the IV push IF the doctor has documented the exam and the diagnosis. You may also just have a problem with the insurance carrier - some carriers (i.e. Geisinger) usually do not pay both office visit and procedure.
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FYI the coding guidelines state that once you have the definitive dx that contains/explains the symptoms then you do not code the symptoms, unless a chapter specific guideline states otherwise. This is redundant coding and not necessary. Some carriers will deny the ov even though the 25 is attached as their radom audits have shown most physicians do not document well for a 25 modifier. These are most usually won on appeal if the documentation does support it.
 
IV pushes...

Thanks so much for all your help. I agree we shoud be paid and even through appeals we have had no luck. Im going to a class this week on billing these such things so I hope I get some answers. I will keep let you all know what I find out.

Thanks,
Darcy
 
Robin CPC

:)
Would modifier 57, "decision for surgery" be the correct way to bill for the E/M ?
 
In you original post you said that you are using the 96374 for the drug? That is only for the administration of the drug. If you are not billing for the drug due to the patient supplying it, then you will need to add that information to the comment section.
 
emrick5 said:
Would a modifer 59 added to the pushes be appropriate?
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Yes, the 59 will get it paid. Because an administration is distinct from the e/m. Check if the Dr./ Nurse performing this used the drug that is billable.
 
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