Are you billing a modifier with 92014 and 92012? If so, which one? Are you billing all three codes, 92133,92134, and 92250 with the eval codes (92014 or 92012)? Look at the Humana for providers website, click on Claims processing edits, search "NCCI" . There may be more specifics in one of those documents. Seems like you need a modifier to me, but Humana can be tricky.Humana started denying Eval and management codes 92014 and 92012 when they are billed with 92133, 92134 and 92250. Reason states this procedure or procedure/modifier combo is not compatible per the NCCI edit. They advised that this is a new CMS rule, but I am not having this issue with CMS. Can someone please assist on this? has anyone else had this issue
We are getting these same denials! Humana told us: According to our policy, which is based on the National Correct Coding Initiative Policy Manual, when an Evaluation and Management (E/M) service is reported on the same day as a global XXX procedure code, the E/M service is payable only if it is a significant and separately identifiable service. To be separately reportable, the physician must perform a significant and separately identifiable E/M service on the same day of service. I would say in this case the definition of “global” here just means that the service is billed for the global service, as opposed to being billed for just a component of the service (i.e technical component or professional component). I would also say that “procedure” just means any service. It does not need to be a surgery to be considered a procedure. A lab test can be considered a procedure."
I do not feel that it is correct to bill our E/M services with modifier 25 as all other payers, including Medicare, reimburse these claims. It's also hard to find exact policies to send to Humana for rebuttal. It seems Humana always has system edits that are incorrect which result in incorrect denials
It's in Chapter 1, section D, end of page I-13. It's crazy though because it's never been an issue before and Humana is the only payer we're having a problem with.With most “XXX” procedures, the physician may, however, perform a significant and separately identifiable E&M service that is above and beyond usual pre- and post-operative work of the procedure on the same date of service which may be reported by appending modifier 25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the “XXX” procedure but cannot include any work inherent in the “XXX” procedure, supervision of others performing the “XXX” procedure, or time for interpreting the result of the“XXX” procedure. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an “XXX” procedure may be appropriate in some instances.
I tried CMS- they referred me to QIO which was an appeals company/ department.If it is a Medicare plan, reach out to CMS. Many years ago I had to reach out to them regarding incorrect bundling denials for portable x-ray for a Medicare replacement plan. It took a while, but the issue was resolved.
I currently have 22 denials, I appealed them all. 5 have been overturned and the rest are still pending or upheld. I called Humana and got nowhere with them. Have you had any luck since you posted this?Humana started denying Eval and management codes 92014 and 92012 when they are billed with 92133, 92134 and 92250. Reason states this procedure or procedure/modifier combo is not compatible per the NCCI edit. They advised that this is a new CMS rule, but I am not having this issue with CMS. Can someone please assist on this? has anyone else had this issue
Hello with the ones being upheld are you adding the mod 25? Ours so far are the ones billed with 99213 or 99214 in addition to the above testing.I currently have 22 denials, I appealed them all. 5 have been overturned and the rest are still pending or upheld. I called Humana and got nowhere with them. Have you had any luck since you posted this?
I don't want to bill with 25 modifier, because once they fix their system error, I don't want all the payments to recoup. We have gotten 99213 and 99214 denials as well.Hello with the ones being upheld are you adding the mod 25? Ours so far are the ones billed with 99213 or 99214 in addition to the above testing.