Wiki I need help

[ClaudetteCancel]

I'm out working at my extern site & have a claim that was denied due "non allowable procedure combination". I spoke w/ an agent who stated 99214 was redundant to 20610 (or vice versa). I didn't think that was correct. Any opinions?

 

[syllingk]

Did you put a -25 on the E/M code?

 

[ClaudetteCancel]

Yes, it was submitted w/ & w/o modifier 25 & 59. They are only paying for 20610 only. The agent told me 99214 was already included but that didn't make sense to me.

 

[mitchellde]

Has the patient had a previous visit for the same reason? Is this a subsequent injection o one billed previous?

 

[Cynthia Hughes]

It will probably be necessary to appeal in writing. Be sure the documentation shows a significant and separately identifiable E/M service at the 99214 level without inclusion of pre-service work (e.g., positioning and injection site identification). Medical necessity of the E/M service should also be identifiable in the documentation (e.g., no previous work-up of the condition requiring the injection, significant change in condition, or there is work-up of another problem/additional management).

It may help to note that NCCI edits allow the use of a modifier to override the edit pairing 20610 and 99214 and that code 20610 was valued based on information that a separate E/M service was usually reported in conjunction with the service so only the actual pre-service activities (eg, discussion of procedure and risks, obtaining consent, positioning and site identification, wait time for local anesthesia) were included in the work value. This explains the .79 physician work units assigned to 20610 as opposed to the 1.5 work units assigned to 99214. Your physician's specialty organization may offer advice or templates for such appeals.

Good luck.

 

[teresabug]

if it was a planned injection from the previous office visit you cannot bill an E/M.