Denial of office visit with 25 mod w/cast application

Kalispell, Montana
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WC is denying OV when billed with mod 25 and application of cast being applied. These were both NP and a detailed dictation / exam / x-ray/ ROS/ PFHS, etc. Orthopedic Pink sheet for Jan 2017 says there are circumstances when E & M can be billed with cast application but doesn't indicate what would allow that. States cast application included in a brief E & M. Would appreciate any feed back on this.


Best answers
Most of the cast application codes are bundled with E/M visits according to the NCCI edit tables.

Most of the cast application codes have 0 postop days and are considered minor procecedures. (Codes with 0 or 10 days are minor procedures).

The E/M for minor procedures is included in reimbursement for the procedure.

An E/M can be billed with minor procedures only it is separately identifiable (e.g., unrelated, above and beyond, or for a separate issue) from what was necessary for the cast.

In most cases, the patient is coming IN for the cast. So any E/M is relavant and related to the chief complaint and the insurer is going to considered it included in the procedure.

These are rules per the National Correct Coding Initiative. Many carriers follow the NCCI guidelines.

If your WC carrier doesn't, then you have an argument against their denial.