Wiki Bundled Office Visit w/ -25

[nittamarable]

We have been getting denials recently from Humana when billing

99214-25 (I70.233, F17.218, I89.0)
11042 (L97.312, L97.212, T81.31XA)

Dx are different for each code. Only thing I can think of is the i70.233 and L97 codes both address the 'right leg' .. BUT we have been getting paid before with previous claims.
Can anyone provide any insight into why humana is denying?

 

[thranowski]

We have been getting denials recently from Humana when billing

99214-25 (I70.233, F17.218, I89.0)
11042 (L97.312, L97.212, T81.31XA)

Dx are different for each code. Only thing I can think of is the i70.233 and L97 codes both address the 'right leg' .. BUT we have been getting paid before with previous claims.
Can anyone provide any insight into why humana is denying?

Have you tried it with a modifier 59 on the 11042? That's how I have billed it in the past and gotten paid, along with the 25 on the e&m. You'll have to appeal with the OV notes to show it was a separate procedure, which I'm sure you know.

If they insist it's bundled, you can always bill by time.

 

[ivorytofu@hotmail.com]

yes, this happening with multiple payors Bundling the OV and the procedure even when the dx are different. This should have paid with a -25. you can appeal. They have read and interpreted the meaning of the modifier in some cases and in other cases they just don't want to pay for both.