jenarnold
Contributor
Hi Everyone,
I'm working with an Endocrinologist who performs CGM (Continuous Glucose Monitoring) using CPT 95251 and also wants to bill an E/M. The provider is having some trouble understanding the 25 modifier guideline despite a few different explanation approaches. I am seeking some words of wisdom on how to explain this in a better way. Also, I would like any feedback on my billing suggestion to the provider (last sentence). Are there rules against not billing a procedure but instead include it in the E/M MDM or time? Thank you in advance for reading and responding.
The basics of the coding situation are: The E/M code, 99215-25, was billed in addition 95251. The conditions are T1DM and polyneuropathy. 99215 was billed based on time of 61 minutes.
One of my explanations was: "The reimbursement for 95251 includes the inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed. This means that we cannot separately bill an E/M for the same work that is already included in the reimbursement for 95251.
99215 cannot include any work related to the diagnosis of T1DM or 95251. The E/M can only include the work for other conditions that are significant and separately identifiable from the CGM service and T1DM. Or, in other words, the E/M can only be billed separately on the same day when a significant and separately identifiable service took place above and beyond the services associated with CGM. In this case, the only other condition was polyneuropathy, which by itself doesn't support 99215 based on MDM.
My suggestion is to bill 95251 and separately bill the appropriate level of E/M with a 25 modifier for the polyneuropathy. Or, bill 99215 alone without 95251."
Thank you again for reading and responding,
Jen
I'm working with an Endocrinologist who performs CGM (Continuous Glucose Monitoring) using CPT 95251 and also wants to bill an E/M. The provider is having some trouble understanding the 25 modifier guideline despite a few different explanation approaches. I am seeking some words of wisdom on how to explain this in a better way. Also, I would like any feedback on my billing suggestion to the provider (last sentence). Are there rules against not billing a procedure but instead include it in the E/M MDM or time? Thank you in advance for reading and responding.
The basics of the coding situation are: The E/M code, 99215-25, was billed in addition 95251. The conditions are T1DM and polyneuropathy. 99215 was billed based on time of 61 minutes.
One of my explanations was: "The reimbursement for 95251 includes the inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed. This means that we cannot separately bill an E/M for the same work that is already included in the reimbursement for 95251.
99215 cannot include any work related to the diagnosis of T1DM or 95251. The E/M can only include the work for other conditions that are significant and separately identifiable from the CGM service and T1DM. Or, in other words, the E/M can only be billed separately on the same day when a significant and separately identifiable service took place above and beyond the services associated with CGM. In this case, the only other condition was polyneuropathy, which by itself doesn't support 99215 based on MDM.
My suggestion is to bill 95251 and separately bill the appropriate level of E/M with a 25 modifier for the polyneuropathy. Or, bill 99215 alone without 95251."
Thank you again for reading and responding,
Jen