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MARYELLENG

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We have started getting denials when we have an e/m code with radiation set up codes (77263, 77290, 77334) we always were able to distinguish with a 25 mod. But are consistantly getting denials lately. What has changed?
 
CMS Coverage Database

Hello,

Check with your insurance carrier maybe they changed their policy? I know that a lot of carriers are getting stricter when it comes to billing e/m's with modifier 25.

Also, according to CMS in radiation oncology, evaluation and management CPT codes are not separately reportable except for the initial visit at which time a decision is made whether to proceed with the treatment. Subsequent evaluation and management services are included in the radiation treatment management CPT codes.

The National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 9 –Radiology Services (CPT codes 70000 – 79999). F. Radiation Oncology 1. Except for an initial visit evaluation and management (E&M) service at which the decision to perform radiation therapy is made, E&M services are not separately reportable with radiation oncology services with one exception as noted below. Effective January 1, 2010, CMS eliminated payment for consultation E&M CPT codes 99241-99255. The initial E&M visit for radiation oncology services may be reported with office/outpatient E&M CPT codes 99201-99215, initial hospital care E&M CPT codes 99221-99223, subsequent hospital care E&M CPT codes 99231-99233, or observation/inpatient hospital care with same day admission and discharge E&M CPT codes 99234-99236.The only radiation oncology services that may be reported with E&M services in addition to an initial visit E&M service are CPT codes 77785-77787 (remote afterloading high dose rateradionuclide brachytherapy...). E&M services reported with these brachytherapy codes must be significant, separate and distinct from radiation treatment management services.
 
The three codes you listed are all for the highest level of complexity. If I had to guess (because you didn't list the denial reason), I'd imagine the payer wants to see some medical documentation to justify 77263 over, say, 77262. Particularly if you only bill the highest level for each service. It'd be like always billing 99215 for every office visit. Either the corporate payers changed their guidelines, or they're cracking down on potential fraud by requiring medical records.

I don't know your practice, perhaps you are only doing the most complex radiology procedures. However, I'd review the section of the CPT manual relating to these services to make sure you're meeting all documentation requirements. 77263 for instance requires custom shield blocks, three or more separate treatment areas, special beam considerations, tangental ports, or highly complex blocking in order to be justified (not all of those, but at least two are required). I'd be willing to bet that 77290 and 77334 have similar requirements.

One other thing, as I used to struggle with these sorts of denials everyday. Not every denial is exact and accurate. There should be a remark code attached to a denial, indicating what exactly is wrong with the claim. If there isn't, that's a whole other problem, but even if there is, the remark codes are generalized and do not necessarily cover every possible situation. Additionally, the people applying the remark codes are human, and errors occasionally happen. Review the remark code to ensure it isn't some simple problem. Once you're assured it isn't a keystroke error, you can go down the rabbithole of LCDs and coverage determinations.
 
We used the 25 mod. As we always were paid with that in the past. Should we be using another mod? Thanks for your help. I am new to this
 
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