Question ER service 99281

[Biller2023]

We billed 99214+OMT code+99281 with place of service 11 as there was some mild presyncopal symptoms after the prolotherapy procedure was done as the patient then alerted that he did not have a lot of food before the procedure.

Horizon NJ Health paid for 99214+OMT but denied 99281 stating "This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements." & "This service is incompatible with previously adjudicated claims or claims in process."

How do we fix this? How do we make Horizon NJ heallth pay for all the 3 CPTs. Thank you.

 

[sls314]

We billed 99214+OMT code+99281 with place of service 11 as there was some mild presyncopal symptoms after the prolotherapy procedure was done as the patient then alerted that he did not have a lot of food before the procedure.

Horizon NJ Health paid for 99214+OMT but denied 99281 stating "This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements." & "This service is incompatible with previously adjudicated claims or claims in process."

How do we fix this? How do we make Horizon NJ heallth pay for all the 3 CPTs. Thank you.

You shouldn't be using 99281.

CPT guidelines for 99281-99285 specifically state that those codes are used for reporting evaluation and management services provided in the emergency department. CPT guidelines also specifically define "an emergency department as an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day."

You're already billing an E/M visit and procedure for the day. Mild presyncopal symptoms associated with a procedure aren't anything I'd look to bill separately for. Certainly not with a 99281.