Wiki Multiple MOD 25 on same claim??

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Madcoder

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Issue. Patient seen for yearly pap with physical. Also seen forseveral other issues with B12 at end of visit.

Coded: Result:

99396 Denied: Benefit included
99214 (25) PAID
P3001 (59) PAID
96372 (59) PAID
81002 (QW) PAID
J3420 PAID

Does this claim really need a Mod 25 on the physical code then drop the 59 on the injection code? I thought that wasn't allowed.

Any insight would be helpful. This is BCBS insurance.

Thanks
 
I would have coded this claim as:
99214-25
S0612
Q0091
J3420
96372

I have had payments and denials on the S & Q-codes depending on the payer. Some carriers will even pay G0101 and Q0091 for the ann pap. This information was learned from a Billing seminar held by an auditor with CrossCountry Coding. Utilizing these codes will allow for 1 adult exam and a female gyne exam on 2 separate occasions and in 1 year. Again, not all payers recognize the S-code. So check with the payers. BCBS of CA pays on these codes. I get more paid than denied.

Why was the P-code submitted? Did you do the path work as well?

Hope this helps.
 
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All insurances will not pay for the 99396 with 99214-25 and the rest even with the mod. 25. You would need to have really strong and separately identifiable documentation to support an E/M above 99213. I would suggest down coding it to a 99213-25 and it should get paid. I have also been adding mod 25 to the preventive code if an additional procedure was performed; example 96372, 11402, 99471 etc. I am also surprised by the use of the P code for a pap in a physicians setting.
 
I've seen things like this with BCBS. For BCBS-NC everything is bundled so I can see why BCBS paid everything but the physical because the pap is considered bundled when performed during an annual physical. An IM injection 96372 is also considered bundled with the associated E/M or physical. So they paid everything else and denied the physical because they won't pay twice.

My coding would have looked like:

99396
99214-25
99000
J3420
81002 QW

It's six of one, half dozen of another. I prefer to avoid -59 if possible, because it is a last resort modifier and forcing an unbundle can be risky.

Just my .02 being a new coder and all but I get paid every time on these types of visits.
 
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