Question E/M denials on same day as surgery

MichaelGA

Contributor
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We are beginning to see denials or recoveries from Humana for E/M claims billed on the same day as a procedure, even when billed with a -25. Is anyone else experiencing this? Anthem BCBS GA issued a policy bulletin this year that they will not pay E/M but I can't find one on Humana's site addressing this.
 

dkissel

Networker
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Flint, MI
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Were they done within 60 days of the last E/M? We see this also. These need appeal if so but don't know where the policy is offhand.
 

danachock

Guru
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Brainerd, MN
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Hi MichaelSL,
There isn't a lot of detail(s) provided with your post. What was the claim adjustment code provided by Humana? Have you ever by chance utilized Modifier 57 (Decision for Surgery)? Like I stated I am unsure what procedure(s) was done or what the E&M provider's note actually states. Hmm ~ dealing with Humana denials in the past... You stated that you googled their website without success. Personally, at this point, I would take the time to call in to Humana or ask your AR person or biller to call into Humana and ask on this denial and discover truly why Humana simply feels that these two codes procedure cannot be billed on the same DOS for reimbursement ~ this may save headaches moving forward dealing with other similar procedures/E&M procedures with Humana to prevent denials. In my prospective if the documentation supports billing both procedsures ~ then please simply appeal it with documentation.
Thanks for listening,
Dana Chock, RHIT, CPC, CANPC, CHONC, CPMA, CPB
 

kl2hdolphin

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Most insurance company's will not pay an E/M on the same date as a procedure as they see this as part of the procedure. Consideration will be give if the E/M is NOT related to the procedure (which is proven usually through an appeal) or if at the E/M it was determined that the procedure was needed (mod 57).
 

ndjstime

New
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We are beginning to see denials or recoveries from Humana for E/M claims billed on the same day as a procedure, even when billed with a -25. Is anyone else experiencing this? Anthem BCBS GA issued a policy bulletin this year that they will not pay E/M but I can't find one on Humana's site addressing this.
WHAT TYPE OF PROCEDURE ARE BEING PREFORMED?
 
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