We have a patient that was seen for medical diagnosis and a preventative visit. The procedure codes that we billed were 99214 with a 25 modifier, 99396, 93000, 94010 with a 59 modifier and 81000. When the claim was processed the insurance bundled 99396 and said it was inclusive to 94010. We sent an appeal to the insurance company stating that the physical and the spirometry are separate procedures and the physical is not a component of the spirometry. The insurance responded and stated ‘ based on guidelines from CPT professional edition and CMS, non-critical care evaluation and management services are considered included in Pulmonary Medicine codes, 94010-94777, unless modifier 25 is appended to the E/M service indicating it meets guidelines for a separately identifiable service.”
I'm confused at what this means because we did append a 25 modifier to 99214. How can I get this preventative visit paid? Do I need to add the 25 modifier to the 99396 instead of the 99214? Or do I append a 25 modifier to both E & M codes?
I'm confused at what this means because we did append a 25 modifier to 99214. How can I get this preventative visit paid? Do I need to add the 25 modifier to the 99396 instead of the 99214? Or do I append a 25 modifier to both E & M codes?