Wiki E/M service denied with 25 mod but procedures paid

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Provider492

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I bill for a PCP office and we always bill 99213-25 and 96372 with a med. The injection has been getting paid and the OV has been getting denied for included or bundled with the 25 mod and distinct diagnoses... I have had this happen A MILLION times with Humana, Aetna, HAP, BCBS, and Molina. Has anyone else had this issue recently in the last month or two?? These office visits should be paid and there are so many getting denied and I don't want to have to appeal each one. Has anyone come across this and has more info?? Any workaround?? I don't see any news about an update to the modifier or any correlation with billing certain procedures....
 
Provider
Is the only thing being done for the doc s visit is an injection? If just injection DO NOT add CPT 99213. If doc manage other medical problems/issues and give or monitor meds, then add those dx codes too linked to CPT 99213. Are you using unspecific dx codes or putting Z code first? That will cause a denial due to sequencing. Modifier 25 can be used if injection is additional treatment on same date of other care
I hope this data helps you!
Lady T
 
TThivierge said:
Provider
Is the only thing being done for the doc s visit is an injection? If just injection DO NOT add CPT 99213. If doc manage other medical problems/issues and give or monitor meds, then add those dx codes too linked to CPT 99213. Are you using unspecific dx codes or putting Z code first? That will cause a denial due to sequencing. Modifier 25 can be used if injection is additional treatment on same date of other care
I hope this data helps you!
Lady T
Click to expand...
99213 has a separate dx (say hypertension I10) and 96372 has a separate (say back pain M54.9) and then he gave toradol. It's still rejecting with completely separate dx and saying it's included, but all diagnoses are completely separate than the E/M service. It just hasn't been making sense and we've never seen this many rejections for included/bundling when the 25 mod is used correctly. He truly does a distinct E/M service that is different then the need for 96372. First this was a MAJOR Humana issue, now I am getting it with BCBS and Aetna. Thank you for your input!
 
Provider 492
Is the admins code for injection added & add nurse name & title too? CPT 96372, J1885 code for Toradol meds and amount given, then dx codes linked. If it is for pain guess injection it is linked to M54.5 The CPT 99213 should be linked to the provider and injection linked to nurse's name who did injection. Documentation of injection by nurse and her name are the time and amount and area of the body.
I hope this data helps!
Lady T
 
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