Wiki Health New England

[Arubaismyhappyplace]

I have a claim question as it is being denied by HNE for an inappropriate modifier. The patient was seen for a complete PE, during the course of the visit the patient brought up new problems so we billed for an office visit as well. She also received an immunization and smoking cessation counseling The original billing was as follows:

99395 denied
99215-25 paid
90715 paid
90471-59 paid
99406-59 denied
2 lines denied so I rebilled as:

99395 -59 denied
99215-25 paid
90715 paid
90471-59 paid
999406 paid

PE is still denying for an inappropriate modifier . I have also tried using modifier 51 on 99395 to no avail. HNE provider services states their coder has said there is a more appropriate modifier but I can't think of what could be possibly used to get the PE paid ... can anyone help solve this problem

 

[Pam Warren]

Just because you appended the modifier doesn't mean it will get paid. Many payers will not pay for both a preventive visit and a sick visit on the same day, even if you append the -25 to bypass their edits. -59 is inappropriate on the preventive visit, by the way.

I think that 'inappropriate modifier' is their way of saying that you've unbundled per their policy, which means no modifier is appropriate, and they're simply not going to pay it when rendered on the same day.

I ran these through the CCI edits:
90471 needs a modifier, as it bumps up agains 99395, 99406 and 99215. There were no other edits, which means that no other modifiers (per CCI) are necessary. I think this is a coverage issue. You can send notes on appeal, but that 99215 with a preventive visit would worry me.

 

[Arubaismyhappyplace]

Hne

Thank You Pam

I did look at the EOB and the Physical is allowed/payable with office visits. Would you mind if I use your reply as part of my appeal?