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Claim denial for NCCI Edit- help please

imcbmcc

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Hello~

I am wondering if someone would be able to help me with a claim denial. Our practice billed out 99472 with a modifier 25 for the provider. The same day the same provider provided sedation; the sedation code billed out was 00635. The claim for 99472-25 was denied for NCCI edit. The insurance provider stated that it was most likely a wrong modifier?

Thank you, in advance of any suggestions or help you may be able to provide.
 

mitchellde

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00635 is an anesthesia code and generally for anesthesia specialties. If you provider performed a spinal tap on a child and required anesthesia, that would not be the code you would use. I would need to see the note to advise further.
 

imcbmcc

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Thank you Debra~

We are just billing for the anesthesia (deep sedation) portion of the service; physician charge. It was a diagnostic LP in which the facility is billing that portion. Does this make sense? I am new to sedation charges for phyicians providing the service. Again, thank you!!
 

mitchellde

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is your provider an anesthesiologist then? if you were called in to provide anesthesia service then most likely that is all you can bill for and not the evaluation and management
 

Davieda Skobel

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Claim denial for NCCI edit

Anesthesia billing is a tricky adventure.
if you have a CPT book there are Anesthesia Guidelines in the front of the anesthesia section that are very helpful.

The 99472 can only be billed once per calendar day and is billed by the physician caring for the patient in the critical care unit. If you were trying to bill for an evaluation prior to the Lumbar puncture it is included in the anesthesia code 00635. The code includes preoperative and postoperative visits.

If you are just billing for the anesthesiologist you just bill the 00635 if it was general anesthesia.If the patient was younger than1 year you also can bill a 99100.

You can check with the insurance company to see if they have any specifics for Anesthesia Billing also.
I hope this helps.
Good Luck!

Just my opinion.
Davieda Skobel CLPN, CPC
Columbus Ohio
 

thomas7331

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Agreed, 99472 is only for use by the physician overseeing the care of the infant - this would probably be billed by the neonatologist and would not be separately payable to an anesthesiologist or other specialist involved in the care. Per CPT, "99471-99476 may be used to report the services of directing the inpatient care of a critically ill infant or young child.... These codes may only be reported by a single individual and only once per calendar day, per patient."

That aside, NCCI edits actually do not allow for any evaluation and management service to be paid on the same date as an anesthesiology service, with the exception of the critical care codes 99291-99292. Per the NCCI manual, "The anesthesia care package consists of preoperative evaluation, standard preparation and monitoring services, administration of anesthesia, and post-anesthesia recovery care...It is standard medical practice for an anesthesia practitioner to perform a patient examination and evaluation prior to surgery. This is considered part of the anesthesia service and is included in the base unit value of the anesthesia code...Similarly, routine postoperative evaluation is included in the base unit for the anesthesia service. If this evaluation occurs after the anesthesia practitioner has safely placed the patient under postoperative care, neither additional anesthesia time units nor evaluation and management codes shall be reported for this evaluation." The manual goes on to say though that If the anesthesiologist provided a critical care service that is separately identifiable from the anesthesia service, then it could be reported. This would be coded with CPT 99291-99292, assuming the documentation met the requirements for these codes and for the modifier 25. Those are the only E&M codes that I'm aware of that are allowed in this situation under NCCI.
 
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