Billing Office Visit + other and then only getting reimbursed the smaller amount

cmiali

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I'm trying to bill a 99213 along with an 81000. I'm getting messages from the carrier that they're paying for the 81000 and bundling the 99213 under it (so I'm being reimbursed less than $10 for a service over $100). Is providing a modifier 25 for 81000 a way to get around this?

Thank you!!
 

Chelle-Lynn

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There is no CCI edit for an E&M and a UA; they should not be considered inclusive. Generally when we see this there is a glitch in the carrier's claim processing system. Using the modifier 25 would not be appropriate from as coding point of view.

If this is occurring with one carrier, I would reach out to their office to review the issue and provide them documentation on the CCI edits. Often times this will need to go higher up the chain of command than the phone representatives; but it is worth the time to get this resolved long term. In addition if this is a carrier that you are contracted with your contracts division may also be resource in getting this error to the right division on the carriers side.
 

cmiali

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Billing Office Visit + other and then only getting reimbused the smaller amount

Wow thank you. That was so helpful!!!!!!!!!!!
 
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