Wiki bundled

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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?

 

[JMeggett]

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?

The insurance is correct. I realize your E&M is 99214, but 99396 is also an E&M. So obviously your E&M's need to be linked to separate ICD-9 codes. The 99214 should be attached to the Dx code that patient is being treated for separately, then the -25 attached. So was the 94010 performed to treat the condition that the 99214 was billed for? The 94010 would have the same Dx code as 99214 linked to it also. Then the 99396 would have it's separate Dx code, V70.0 or whatever. Does that make sense? So it shows really clear to the insurance that the modifier -25 WAS put onto the correct E&M because both 99214 & 94010 were for the same condition SEPARATE from the preventive visit. I hope this helps!
Jenna

 

[btadlock1]

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?

Yes, you need a 25 modifier on both. The guideline they're referring to says that 'significant separately identifiable E/M codes' need a 25 modifier, which some commercial payers interpret as, 'ALL E/M codes' need one. It's a relatively common denial. I usually see them bundled with 94060, and 94640. FYI - if you ever bill any of those codes (94010-94777) with an injection administration, the injection code (96372) will bundle, too, and will require a 59 modifier to process Hope that helps!

 

[ttcoding]

Thanks for all the help