Wiki Bundling problem with United Healthcare....

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cpicerno

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Hi!! I am having a problem with United Healthcare paying a claim, I am billing the E/M 99204 with a 25 modifier, 96372, J0696 X 3, 51701 with a modifier 59, 87804, 87430, 85025, 81003, 36415. In exactly that order and they are denying it because of the order of the bill. Does anyone know what order would be correct to have this bill paid??
Thanks!!
 
How about this.....I would do the 99204 - 25, 51701 , 96372 -59 with your drug X3 and then your labs plus draw fee.
 
Bundling problem

Check you ICD code if they correspond to the CPT line up. Injection come first, then the drug, then the office visit with modifier. the rest can be listed the way it is listed. Cath placement maybe bundled to the urinalysis (if the purpose of cath is to measure the residual urine, you can bill with modifier 59), check CCI edits. 36415 is bundled with 85025 and 87430.
You claim should look like this: (ICD code should correcpond with the line-up)
96372 Injection
J0696 x 3 (250/mg + NDC) Ceftriazone sodium injection
99204-25 New pt OV (presenting problem moderate to high severity, 99203-25
presenting problem is moderate severity)
81003 Urinalysis
51701-59 Straight catherization (use if the purpose is to meaure amount residual urine
following urination, otherwise it is bundled).
85025 Complete CBC
87430 Streptococcus, Grp A
87804 Influenza
 
I posted that answer last fall before the changes to guidelines came out. Now, I would look at your office visit, taking out any verbiage about the injection. See if you really have enough documentation to charge the office visit as something separately identifiable. If you do, I would bill the office visit, the injection and the medicine, because that's what you did. If you don't have enough documentation for the office visit to stand on it's own, and show that a decision was made to do the injections, then I wouldn't appeal the office visit if they deny it. You need to feel confidant that there was enough documented to justify all three. I usually look at what options were offered to the patient, and then make sure that there is something that says after all these options were explained, the patient decided at that point to get the injection. Hope that helps!
 
That is what I was thinking. I don't code these, the AR person had asked me b/c ins. co. paid the meds (J codes) , but the 99204 denied with the 96372. She said she sees this from most ins. co. I told her to tell the office to bill it out w/a mod 25. She can't see the notes, just what has paid/denied. I'm thinking it denied b/c the OV is not separate from the 96372. Therefore, I don't think it would be ethical to bill the OV w/only the J codes and leave out the 96372? I think that's what the office will want to do. In that case I would think they should only code 96372 w/the J codes?

Thanks in advance!
 
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