jenmendoza
Contributor
Hello everyone! I have a quick question:
So recently we have been getting denied claims pertaining to E/M + Phototherapy visits by this one insurance. Typically, the phototherapy visit is considered as a "clinical visit" in our practice as the administrator for the treatment is not the provider (MD/PA) - these are also visits that do not need an appointment beforehand as patient can schedule on their own time based on their availability. With that being said, there will be instances where the patient comes in for an E/M visit, sees the provider and then goes directly to their phototherapy treatment (in the same office).
The usual remedy we have been doing is that we have been coding in mod 25 to the E/M code, which has been giving us payment. But considering how the phototherapy is a "clinical visit", it should have been treated as a separate entity from the E/M visit - so we have begun coding the E/M visit on its own, then the clinical visit (if it happens) on its own as well.
Because of this, we have been getting some claims denied under the presumption that the provider is only allowed one visit per day, which I would like to get more clarification on - since even if we try to correct the claim and add the modifier 25 in (as how we originally coded), they uphold the denial with said reason.
On top of that, in the cases that they do pay afterwards, they don't even pay us the contracted rate that they would have if we coded it with modifier 25 to begin with.
I would like to kindly get your input on this and what would be a better approach to this!
* For reference, insurance states that they reference from the CA Medi-Cal billing guidelines
So recently we have been getting denied claims pertaining to E/M + Phototherapy visits by this one insurance. Typically, the phototherapy visit is considered as a "clinical visit" in our practice as the administrator for the treatment is not the provider (MD/PA) - these are also visits that do not need an appointment beforehand as patient can schedule on their own time based on their availability. With that being said, there will be instances where the patient comes in for an E/M visit, sees the provider and then goes directly to their phototherapy treatment (in the same office).
The usual remedy we have been doing is that we have been coding in mod 25 to the E/M code, which has been giving us payment. But considering how the phototherapy is a "clinical visit", it should have been treated as a separate entity from the E/M visit - so we have begun coding the E/M visit on its own, then the clinical visit (if it happens) on its own as well.
Because of this, we have been getting some claims denied under the presumption that the provider is only allowed one visit per day, which I would like to get more clarification on - since even if we try to correct the claim and add the modifier 25 in (as how we originally coded), they uphold the denial with said reason.
On top of that, in the cases that they do pay afterwards, they don't even pay us the contracted rate that they would have if we coded it with modifier 25 to begin with.
I would like to kindly get your input on this and what would be a better approach to this!
* For reference, insurance states that they reference from the CA Medi-Cal billing guidelines