Wiki Humana denying any OV billed with any testing or vaccines at the same visit

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JodiLynn

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Did anyone else start receiving denials for O.V mid December anytime it was billed with any vaccine or testing ( 87880,86308, ect) ? We are pediatrics...and yes we are billing with the correct modifiers. Its across the board, not even plan specific within Humana. I'm reaching out to my Humana rep but since we are through an IPA, its kind of a process. To make matters worse we are no getting refund request for OV billed September and on. stating its "overpaid due to coding issues related to claim history"
this claim was billed as follows 99213 -25 and then 90658 & 90460 there is no reason to take the $$ back. I fear there is a claim edit in their adjudication system that's went hinky. So I'm curious, has anyone else had any issues?
 
we are receiving the same problems. Our rep said we need to send a spread sheet to an elevated help line. They still have not responded. I sent an appeal on every single one of our claims with information printed out on the web showing how to bill this correctly. I am at a loss and do not know why this is changing all of the sudden. If anyone gets any information that can help please let me know.
 
I looked up the NCCI Edits. I think someone at Humana has made a booboo. I would like someone else to read this and see if they catch the same thing I did. I have also sent CMS an email regarding this. on the NCCI Edits it says that CPT code 99211 is not separately reportable with 90460-90474 it does not say that you can not bill well visits with immunization codes. I also had a visit that denied and it was a follow up with a 25 modifier and the flu shot and immunization. It did not cover the immunization. The NCCI edits state that you can bill them if it is significant and separately identifiable, in which you should append a 25 modifier. Humana also denied my claim like that. For some reason it will not let me post the link.
 
We have had this problem with Humana for a long time. We are dermatology, so we frequently bill an office visit and a minor procedure (for two separate, unrelated problems) on the same day. We correctly add modifier 25 to the office visit, but Humana either denies it or (more frequently) pays and then asks for their money back.

The solution provided by our Humana rep is to call claims to ask that it be reconsidered (even though we know from past experience that calls and letters are useless) and get a reference number. Then you send an email to provider services (HumanaProviderServices@humana.com) explaining why the office visit is payable. The email has to include the reference number as proof that you "attempted" to resolve the issue through the normal channels.

This has been successful for us in every case. So although it's a ridiculous nuisance, it does the job.

Here is the wording I use for justifying that the office visit is payable: (Since we see mostly Humana Medicare Advantage patients, they have to follow Medicare guidelines): "Per the Medicare Claims Processing Manual (Rev. 2714, 05-24-13), Chapter 12, section 30.6.6(b): CPT Modifier “-25” - Significant Evaluation and Management Service by Same Physician on Date of Global Procedure: 'Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure.'”
 
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