Wiki E/M and 90471 denying...HELP!

[anne32]

So I guess I wasn't very clear in my original post....
It a patient comes in for a diabetes appointment and receives the flu shot we would bill like this:

250.00
V04.81

99213-25 250.00
90658 V04.81
90471 V04.81

Previously we were billing without the modifier 25, but then the carriers started denying saying mod 25 was required.
NOW we are billing with mod 25 as shown above, but Utah Medicaid, PCN, and Baby Your Baby are starting to deny even when it is attached. When I called Utah Medicaid they are saying they will only cover the E/M OR the 90471, but not both. And of course they are paying the 90471 because it is a lower billed amount and denying the office visit. The person I spoke with also said that it will deny this way if both E/M and 90471 are on the claim regardless if there is a mod 25 attached or not.

My question is....Is anyone else having this issue? Is there a different way to bill this to get reimbursed? I don't think its right to only get payment for EITHER the E/M or the 90471 when in some cases it's perfectly correct to bill both!

 

[Herbie Lorona]

I don't bill any of those Insurance companies but I have not have any issues with getting both paid. My local Medicaid has not given any issues. If you called them and they said they don't pay both those codes when billed together no matter if the modifier was used or not then you have a problem. I would talk to your provider rep and see why they are not allowing this. You may also want to see what they say as to how they want the flu shots billed.

 

[ssalandy]

It is a stretch, but have you tried putting the modifier 59 with 90658. In other words try billing as follows:

99213/25 250.00
90658/59 V04.81
90471 V04.81

Maybe that would work for you.

Sherill Salandy, MHA, CPC
ssalandy@yahoo.com