Wiki Billing E/M with Osteo Manipulation

[cbutsko]

I am a collector for a large multi-specialty practice in Oklahoma. One of our insurances has long since stopped reimbursing us for both the E/M code and the osteo manipulation code when performed at the same visit by a provider whose specialty is osteomedicine, regardless of dx codes used and a modifier 25 appended to the E/M code. We've tried resubmitting the claims with medical records to appeal the denial of the E/M-25 code without success. It is always denied as incidental, even when the E/M-25 code is for a dx like....chest pain or diabetes and the OM tx code was for....say, low back pain.

Interestingly enough, an E/M-25 with an OM tx will both be paid when submitted w/medical records if the provider is a Family Practice, OB, or other specialty. It is only the Osteomedicine providers who are consistently denied as incidental.

Anyway, my question is this. If our osteomed provider renders services that are primarily E/M based/focused, but also does an om tx, would it be acceptable coding to either not charge for the om tx at all, or charge it at 0.00 and charge for just the E/M code? I'm pretty sure that even if we post the OM tx at 0.00, we're still going to have to append a 25 to the E/M code, which is always then denied as incidental even with medical records. However, in my mind we "have to charge for the services documented" and so we would be required to post both codes?

I think I may be confusing myself at this point. Any input/feedback would be greatly appreciated!

Thanks,

Cate

 

[ajs]

I am a collector for a large multi-specialty practice in Oklahoma. One of our insurances has long since stopped reimbursing us for both the E/M code and the osteo manipulation code when performed at the same visit by a provider whose specialty is osteomedicine, regardless of dx codes used and a modifier 25 appended to the E/M code. We've tried resubmitting the claims with medical records to appeal the denial of the E/M-25 code without success. It is always denied as incidental, even when the E/M-25 code is for a dx like....chest pain or diabetes and the OM tx code was for....say, low back pain.

Interestingly enough, an E/M-25 with an OM tx will both be paid when submitted w/medical records if the provider is a Family Practice, OB, or other specialty. It is only the Osteomedicine providers who are consistently denied as incidental.

Anyway, my question is this. If our osteomed provider renders services that are primarily E/M based/focused, but also does an om tx, would it be acceptable coding to either not charge for the om tx at all, or charge it at 0.00 and charge for just the E/M code? I'm pretty sure that even if we post the OM tx at 0.00, we're still going to have to append a 25 to the E/M code, which is always then denied as incidental even with medical records. However, in my mind we "have to charge for the services documented" and so we would be required to post both codes?

I think I may be confusing myself at this point. Any input/feedback would be greatly appreciated!

Thanks,

Cate

It sounds like the insurance is using the Taxonomy code for your osteomedicine docs and using that to justify not paying separately for E/M.

I assume you are billing in the 98925-98929 range for osteopathic manipulation. It does state in the guidelines prior to those codes that a separate E/M is allowed with a modifier 25 and it may be prompted by the same symptoms as for the manipulation.

Have you called the insurance and asked someone (in person) why they continue to deny when the separate E/M is clearly allowed and is paid when billed under other providers? If not, then I would suggest that be the next step with that insurance. You want them to give you a policy in writing that states their coverage position. It may even need to go to the level of a provider- to- medical director appeal. Pull out the guidelines as written in the CPT book and have a copy of those available when appealing, it can also help to show that other insurance carriers to pay in this situation.

Be sure the documentation in the chart very clearly shows the extra work that justifies the addition of the E/M code.

Good luck and don't give up!

 

[cbutsko]

Thank you for the response. I have contacted them numerous times, both by phone and by mail. I've submitted every single E/M w/om tx claim with medical records for the last 3 1/2 years, many of them with copies of the cpt coding guidelines for the modifier 25. I've seen maybe 1/2 dozen pay both charges out of thousands submitted. When I call them their only response is that it is an "internal edit" within their own policies, yet they cannot give me that policy in writing. Since they are a government insurance agency they have much more leeway in what they have to document for their providers.

In discussing it with our om providers, they asked me to post the question that I included in my original post. In my opinion, if they provide an om tx, it has to be charged out. You document what you charge and you charge what you document, is how I was taught to code claims.

Thanks again,

Cate

 

[ajs]

Thank you for the response. I have contacted them numerous times, both by phone and by mail. I've submitted every single E/M w/om tx claim with medical records for the last 3 1/2 years, many of them with copies of the cpt coding guidelines for the modifier 25. I've seen maybe 1/2 dozen pay both charges out of thousands submitted. When I call them their only response is that it is an "internal edit" within their own policies, yet they cannot give me that policy in writing. Since they are a government insurance agency they have much more leeway in what they have to document for their providers.

In discussing it with our om providers, they asked me to post the question that I included in my original post. In my opinion, if they provide an om tx, it has to be charged out. You document what you charge and you charge what you document, is how I was taught to code claims.

Thanks again,

Cate

Ah, the key word here is "government insurance agency". Many government plans make up their own rules on reimbursement. You are right, the provider documents what is done and you code and bill what was documented. At the end of the day, you have done all you can to get reimbursed. Know that just because there is a guideline in the book does not mean that every insurance is going to follow the same guideline!