Wiki Have you ever heard of being paid less because you use a 25 mod?


Emmaus, PA
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I just had a conversation with Magnacare (a NY, NJ plan) They paid one claim for 99213 with no modifier at $100 as the allowed amount. The next claim was billed 99213 with a 25 Mod due to another code also being billed with E&M. They told me the allowed amount when 99213 is billed with a 25 mod is $38.50. HOW is the correct or LEGAL????? The plans are EXACTLY the same can they allow less then even MEDICAID if you use a modifier? They didn't pay anything on the second line, and the allowed amount for that line was a whopping $4.60! That is just highway robbery. Can someone please tell me how they can get away with that???:mad::confused:
I would demand them to prove it is legal, even if that means having them produce the policy or talking to a higher up. I have not heard of that. I know some payers have rules misinterpreted, etc. This may be their individual policy too..
I believe its completely legal. Some payers around the country are looking into reducing E&M by 50% on same day as a procedure (an attempt to combat the incorrect reporting of E&M). I know this is more than 50% but why do you think it would be illegal? What does your contract state? I tried to look up policies on their website but I assume they are probably only available by sign on.
If you can show with the chart note where you did not include any elements of the diagnosis for the procedure in the assignment of the 99213, then you may be able to appeal this. The payer is assuming that some of the elements of the assessment and MDM are for the medical necessity for the procedure which is inclusive to the procedure so they are "carving it out". If you can show where there are no elements in the examination and the MDM that are part of the diagnosis and assessment for the procedure then you have a case for full payment.