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My doc is billing out 99213, 96523 and J1642 in one visit. The only thing paying is the E/M.
The next visit she is billing a 99213, 96365, J7050 an dA4212 and 96360.

Can someone help with the correct way to bill these two days.
 
smsullivan said:
My doc is billing out 99213, 96523 and J1642 in one visit. The only thing paying is the E/M.
The next visit she is billing a 99213, 96365, J7050 an dA4212 and 96360.

Can someone help with the correct way to bill these two days.
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Sorry I do not have my books in front of me and have not coded hemonc in years, but I do want to point out that you need a mod 25 on the ov if it is supported and also you CANNOT code a 96365 and a 96360.. it would need to be 96365 and 96361. You cannot code two primary codes.
 
Neither 96523 or the J1642 are billable. The only one billable would be the 99213 for the first day. The second ay you would bill 99213, 96365, j7050 and 96361
 
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Why are you using the 96365? If you only have J7050 I believe you would use the 96360 for the first hour and then the 96361 only if it ran 31 min or more over the first hour. Also 96523 is billable if that is your only service for that dos it can not be reported with anything else for same dos.
 
This all comes down to what is the reason for the encounter? If the first visit is for a port flush then that is what you can charge only, with a dx code of V58.81. On the other hand if this was a visit for other reasons and the physician decised to flush the port (or have staff do it) then it is inclusive to the office encounter and not billable, also it tells you this in the CPT book. For the second visit, what was the reason for the encounter, it does not make sense to bill for a therapeutic infusion without a substance other than the saline. So the question is was this for dehydration, then you would use the 96360 for the first 31 minutes to an hour. Otherwise what was the therapeutic reason for the saline. And the previous poster is correct that you cannot hav more than one initial service per vein access, if you have 2 veins accessed then you can bill 2 inital services using the 59 modifier. Also start and stop times must be documented or there is no billable infusion. You cannot charge the A4212 as it is inclusive with the infusion charge.
 
So just to make clear of what is being said. If the only reason for the visit is the 96360 then you should not be billing a E/M with modifier 25. To me you shouldn't be able to bill the E/M as well if that was the only reason the patient was there. Our doctor thinks they should get paid for an E/M visit too.
 
If you have scheduled the patient for any procedure then it goes to reason that the assessment for the necessity of that procedure has already been performed and charged for, therefor you do not get to charge an E&M. If the procedure is decided on after the assesment of the patient at the same encounter then depending on the documentation you might have an E&M. In my answer to the above, the first day they wanted to charge a port flush (96523) with an E&M, however this cannot be done, the patient has a port so to have a patient come in for the flush is a preplanned activity, and if not then it is considered part of the E&M. As far as your question for the coding of rehydration 96360 with an office ov then the answer is possibly, as long as the assesment meets the criteria for use of the 25 modifier then yes you can charge the E&M and the 96360 (assuming it runs for a min of 31 minutes). But if the rehydration was already planned before the patient presents or the documentation does not meet the criteria of significant and separately identifiable then you can charge only the 96360.
 
per cpt book, if you are doing a flush at the time of a visit it is not payable. look right below code 96523 (Do not report 96523 if any other services are provided on the same day) Also if you check NCCI guidelines you will see 96523 is bundled into EVERY other code.
 
25 continued

Okay say for example a patient has an office visit almost every day. Every day the clinic is charging the following

99213 25
96360 iv infusion
j2271 Morphine
j2550 Promethaazine
j3660 diazepam

All visits have these same dx

564.1
789.09
787.01

What I don't understand is how they can charge a 99213 25 every time. It doesn't appear to have any new symptoms and I mean they come in every day. The clinic tells me that they were told by Blue Cross rep they could use a modifier 25 on the E/M and get paid. Which they have been getting paid. It just doesn't seem logical to me or right why one could charge 99213 as well as the others if all the procedures are the same. Wouldn't they have to have an additional complaint to have a new e/m code everyday??
 
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