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Wiki E/M Visit with CMS Preventative Screening

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eajenn

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I have a claim that was billed 99213-25 and G0442 Annual alcohol misuse screening. The E/M were billed for different diagnosis codes than the G0442. It is my opinion that G0442 should be paid since the modifier 25 was billed on the E/M. Per NCCI edits a modifier is allowed. Someone else disagrees with me. This person states to override NCCI Edits that the modifier 25 has to be billed on both codes. I do not agree. Can someone help me either verify I am correct or explain to me why I am not. I cannot find any information stating the modifier 25 has to be billed on both codes to override the NCCI edit and I have not ever billed modifier -25 on anything but the E/M code.

I appreciate the help on this!
 
The problem I am having is finding verbiage in the CMS manual to support my opinion on this. The person who disagrees with me is an analyst and I am a coding supervisor. I am being told I cannot adjust these claims so I need something to back myself up. Do you know where I can find something?
 
eajenn said:
The problem I am having is finding verbiage in the CMS manual to support my opinion on this. The person who disagrees with me is an analyst and I am a coding supervisor. I am being told I cannot adjust these claims so I need something to back myself up. Do you know where I can find something?
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CMS NCCI Edits FAQs:
https://questions.cms.gov/faq.php?id=5005&rtopic=1867&rsubtopic=7005

scroll down a little to "How should modifier "-25" be reported under the Natiional Correct Coding Initiative (NCCI)?"

it clearly states that the modifier should be added to the E/M.

hope this helps.
:)
 
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