Wiki E&M Denials Blue Cross

mbellar

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Is anyone having issues with BC/BS denying E&M stating pre /post care included when an E&M is being billed w/ minor procedure when another claim is on file within the past 90 days for same dx codes?
 
Are you using both modifier 24 and 25 in this situation?
No only mod-25-
example
99213-25 L70.0- DOS 12/1/21 and DOS 10/5/21
17110- B07.8

Payer is denying as pre/post care- stating CMS guidelines state you cannot bill same dx within 90 days with minor procedure with same dx for E&M
Appeals are being upheld
 
No only mod-25-
example
99213-25 L70.0- DOS 12/1/21 and DOS 10/5/21
17110- B07.8

Payer is denying as pre/post care- stating CMS guidelines state you cannot bill same dx within 90 days with minor procedure with same dx for E&M
Appeals are being upheld
I may not be current on my information, but I have never seen or heard of anything from CMS that says this. Have you asked them to direct you to the document where this is stated in writing? Or if it's their own policy, have you reviewed it to see their own plan guidance or what criteria they will accept on an appeal? Which BCBS plan are you dealing with here? Each state and sometimes each plan within the state will have their own policies.
 
I may not be current on my information, but I have never seen or heard of anything from CMS that says this. Have you asked them to direct you to the document where this is stated in writing? Or if it's their own policy, have you reviewed it to see their own plan guidance or what criteria they will accept on an appeal? Which BCBS plan are you dealing with here? Each state and sometimes each plan within the state will have their own policies.
 

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This is what BC/BS of Georgia sent to us- I asked them to show me this policy on there website but they didn't- this is new to me as well
Claim denial is M144- appeals are being upheld and we are spending hours on phone with customer service reps are being told about this CMS policy on every phone call
 
This is what BC/BS of Georgia sent to us- I asked them to show me this policy on there website but they didn't- this is new to me as well
Claim denial is M144- appeals are being upheld and we are spending hours on phone with customer service reps are being told about this CMS policy on every phone call
OK, I think I see what's happening, it's not actually a CMS policy - it says it's based on a CMS policy. The CMS policy is the same as it's always been - the E/M is payable if it is significant and separately identifiable. It says nothing about the same diagnosis, so that part is the BCBS policy. I've never dealt with the GA plan, so I'm not sure exactly what you're up against here and maybe someone from that state can add info, but here's my recommendation as to what I'd do in the situation.

First of all I'd look at the appeal responses to try and see if they are actually reviewing the documentation but denying the appeal because they feel the documentation doesn't support the modifier, or are they just denying everything outright without even looking just because of the policy. If it's the first, then you might need review your providers' use of the modifier and have them improve documentation when they are using that modifier (or stop using if it truly doesn't support it). On the other hand, if BCBS is not even considering the documentation and are just enforcing the policy, then you probably shouldn't be wasting your energy on the appeal and may want to try to escalate this with a network representative (which may or may not help). If that's the case, I would track the money your practice is losing due to their policy. Keep an eye on it over time and if it amounts to a lot, then your providers may want to exit the contract, or when their contract is for renewal they can try to request a contract clause be added that exempts your provider from this particular policy or else negotiate a better rate in order to compensate for the loss of revenue.

Hope this may help some.
 
Last edited:
Great advice from Thomas above. It's interesting that their policy states an E/M billed with a procedure will be denied if the patient had a previous visit with the same or similar diagnosis. That would mean if you saw the patient 2 years ago, the patient returns today and you perform a very thorough evaluation and determine the problem is much worse and a minor procedure is needed, they will not pay the E/M today, even with a justified -25.
I will just add from experience (not with this specific carrier), some plans will simply deny the E/M without even asking for documentation. I then submit a very basic appeal letter along with the documentation. That is successful 98% of the time. I would emphasize to ensure that your -25 use is appropriate. Otherwise, you are proving their point with an across the board initial denial.
If BCBS GA really will not pay for an E/M that is truly significant and separately identifiable despite appeals/escalation AND your practice does a lot of minor procedures, you really should consider terminating the contract.
 
Great advice from Thomas above. It's interesting that their policy states an E/M billed with a procedure will be denied if the patient had a previous visit with the same or similar diagnosis. That would mean if you saw the patient 2 years ago, the patient returns today and you perform a very thorough evaluation and determine the problem is much worse and a minor procedure is needed, they will not pay the E/M today, even with a justified -25.
I will just add from experience (not with this specific carrier), some plans will simply deny the E/M without even asking for documentation. I then submit a very basic appeal letter along with the documentation. That is successful 98% of the time. I would emphasize to ensure that your -25 use is appropriate. Otherwise, you are proving their point with an across the board initial denial.
If BCBS GA really will not pay for an E/M that is truly significant and separately identifiable despite appeals/escalation AND your practice does a lot of minor procedures, you really should consider terminating the contract.
they are saying within 90 days, if the patient had the same dx on the E/M with a procedure
 
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