Wiki Billing OV with modifier 25 with joint injection

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ahousner

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Hello, I bill for an orthopedic practice. Our doc's are billing joint injections with an office and using mod 25. The insurance companies are rejecting the ov.
What is the best way to appeal the denial?
Our documentation supports the ov.
 
ahousner said:
Hello, I bill for an orthopedic practice. Our doc's are billing joint injections with an office and using mod 25. The insurance companies are rejecting the ov.
What is the best way to appeal the denial?
Our documentation supports the ov.
Click to expand...
I’m a biller in an ortho office as well. I’m getting the same types of denials. The ov’s that are getting denied are because the patient had an injection into the same body part for the same reason as a previous ov. If that’s the case with your denials, I’m not sure there is anything you can do to fight it, unless the patient presented with a new problem.
 
Was the injection planned ahead for that day or was it discussed and decided in the room at the time of service? That would be the difference. If it was planned ahead you cant really argue the insurance to pay for the OV. If the Inj was discussed and decided at the time of service than you can argue for payment.
 
vgriffin said:
If this is for a BC patient, as of 10/1/20 the issued this reimbursement update for joint injections and ear lavage being not separately reportable with an office visit regardless of modifier usage.
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I'm not seeing on that document where it says that (it says not payable with ultrasound or anesthetic-lidocaine); where does it say office visit? I asked because I remember them sending out a notice that they were not paying injections with office visits which caused us to stop doing injections with office visits... if the doctor is going to spend 30-45 minutes on a pain management visit and not get paid for it because he then decided the patient needed an injection - well, nope, not gonna happen in our office.

I've been looking for that notice ever since they sent it out, and cannot find it.
 
In our orthopaedic office, we're billing office visits with a -25 modifier and the injection code 20610 with the J code, and they're denying the office visit even if it's a new patient visit. If it's a follow-up visit, I can understand it, but if you're seeing the patient for the first time, it makes no sense to deny the office visit since you need to do a full evaluation and diagnose the condition. Does anyone know a way to get insurers to pay?
 
TPeniston61 said:
In our orthopaedic office, we're billing office visits with a -25 modifier and the injection code 20610 with the J code, and they're denying the office visit even if it's a new patient visit. If it's a follow-up visit, I can understand it, but if you're seeing the patient for the first time, it makes no sense to deny the office visit since you need to do a full evaluation and diagnose the condition. Does anyone know a way to get insurers to pay?
Click to expand...

Nope, this is the new normal. Don't do an injection with a new patient evaluation.
 
Melissa Harris CPC said:
I have received these denials and appealed with the medical documentation that the decision was made at the visit because of acute pain. They have reprocessed the claim after that.
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Do you code a particular way, such as inserting a pain diagnosis code, or do you have a standard phrase that doctors use in their documentation. I'm just thinking that if the assessment of acute pain is not specifically stated as being the reason for the injection, just attaching the medical documentation doesn't seem to be sufficient. We've submitted with the encounter notes and many times the original decision is still upheld.
 
ashleijackson said:
I’m a biller in an ortho office as well. I’m getting the same types of denials. The ov’s that are getting denied are because the patient had an injection into the same body part for the same reason as a previous ov. If that’s the case with your denials, I’m not sure there is anything you can do to fight it, unless the patient presented with a new problem.
Click to expand...
We have found if you saw the patient recently for the same diagnosis and they are coming back for an injection for that same diagnosis, they won't pay for another OV.
 
sarab86 said:
Was the injection planned ahead for that day or was it discussed and decided in the room at the time of service? That would be the difference. If it was planned ahead you cant really argue the insurance to pay for the OV. If the Inj was discussed and decided at the time of service than you can argue for payment.
Click to expand...
It’s normally decided at that visit, however a lot of times the patient is coming in for the same issues. So they may have been seen a couple months (or even 6 months to a year) prior for the same reason. I’ve just been sending records & asking for reconsideration. About 50% of the time they are getting paid this way.
 
TPeniston61 said:
In our orthopaedic office, we're billing office visits with a -25 modifier and the injection code 20610 with the J code, and they're denying the office visit even if it's a new patient visit. If it's a follow-up visit, I can understand it, but if you're seeing the patient for the first time, it makes no sense to deny the office visit since you need to do a full evaluation and diagnose the condition. Does anyone know a way to get insurers to pay?
Click to expand...
This is odd! What’s the denial reason your receiving? Are they denying as inclusive?
 
Weird question related to this..One of my billers (not a coder) states she put a -59 modifier on the 20610 and both the office visit and injection paid. She did it once and asked me on receiving payment if this was ok. I don't feel this an appropriate use of -59.
Any thought?
 
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