Wiki Bundling in Cardiology

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amym

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We recently started receiving denials when we bill CPT 99219-25 and 93306-26 on the same day. Is it appropriate for an insurance company to deny these two codes when billed same day? What logic can I use to appeal this?
 
I don't see how they could deny it because of the modifiers. Modifier -26 simply states that our physician performed only the reading portion of the echo and -25 to indicate a seperate E&M same day as the test.
 
What are your denial codes? All insurance companies must give reasons for denials, it's hard to say what the problem is without knowing what reason they gave for the denial
 
"reimbursement for this service is considered to be a portion of another service which has been allowed or the service can not be billed separately"
 
If the physician is only doing the interpretation of the procedure, you cannot bill the procedure (93306) because the procedure was done already. So, that code with modifier -26 would not apply. Was the patient coming in for the result of the procedure, if so, it would be a follow-up (V67.9) because the interpretation is included in that procedure code.
 
Patient is in observation setting at the hospital and they are not there just to get the results of the test. I understand if the physician is relating only the results of the test that they cannot bill for follow-up care but this is an initial new patient visit.
 
I stand corrected on the follow-up code since the patient is in a hospital under observation but I still disagree with billing the 93306-26 because the physician is just communicating the result of that procedure to the patient which was already interpreted.
 
Maybe another physicain is already billing those codes?
For instance maybe the tech who performed the 99306 forgot to put the TC modifier on that procedure and was paid for the whole thing so they are denying your provider.
Was this patient admitted to OBS under your physician? If not you would use the appropriate outpatient/office (99201-99205 or 99211-99215) range visit level code for the services provided with an outpatient place of service and the -25 modifier. That could possibly be the problem.
A while back the hospital our doctor's do some work at had hospitalist claiming the OBS admits and regular admits that our doctor's were actually performing (and some of their procedures as well that maybe they had assisted with but not performed on their own. Our docs had performed them) and we had to call their billing department and have it straightened out. Of course we sent notes to the insurance company first showing that our doc was the admitting/operating physician as well.
The one denial you listed looks as if it is the denial for 99306-26. What was the actual denial for 99219-25?
 
It is only BCBS that is denying 93306-26 when billed with 99219-25. They are paying for 99219-25 but not the 93306-26. This is a what they said in the letter after we appealed: "A patient care provider who review the results of echo studies performed in an inpatient or facility based outpatient setting, is performing an integral part of a global service rendered under the provider's E&M service. According to the AMA, E&M cdoes also include the review of test results performed by other providers".
 
The -25 modifier should not be used on your E/M service. It would only be needed if there was a bundling edit or there is a global of 0-30 days and -57 for 90 days.

Just had this clarified by Medicare last week on Modifer seminar.
 
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All of our payers would deny an E/M billed same day as a nuclear stress or ETT. We append the modifier only if the test resulted in the physician ordering the test same day.
 
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