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Wiki NCCI edits are killing me!

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rhondareeney

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Any suggestions for billing office visits with pulmonary function testing and managing to clear CCI? We are appealing ourselves to death and some payers are starting to revoke the payments they made!:confused:
 
Yes we are using the 25 modifier, they are bundling visits with the testing and paying the testing. We are having to appeal everything and get paid about 2 months out!!

I am wondering if I could can the 25 on the E/M, and use a 59 on the testing?
 
If you are getting paid on appeals, then clearly the services are medically necessary.

Modifier -59: "Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter,different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries)not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."
Modifier -59 is an important NCCI-associated modifier that is often used incorrectly. For the NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.
NCCI edits define when two procedure HCPCS/CPT codes may not be reported together except under special circumstances. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or different patient encounters. Carrier processing systems utilize NCCI-associated modifiers to allow payment of both codes of an edit. Modifier -59 and other NCCI-associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.
 
I am having same issue with spirometry testing at time of office visit. Medicare advised me to use 59 mod on visit 99214 instead of 94060. Should I use mod. TC? I am lost.
 
Medicare told you to put a 59 on the office visit? I wasn't aware it could go on an office visit. I work for inf dz docs. Many times the doc sees pt in the hospital for a 99232 on the same day they are released. The pt will follow up at our office the same afternoon to start infusion therapy...usually due to an infection requiring antibiotic treatment. The hospital follow up (99232) is getting denied and bundled to the office antibiotic infusion treatment. There is no reason why we shouldn't be paid for the hosp visit as well as the office infusion treatment. The 25 modifier on the 99232 has not made any difference. Does anyone else know the answer?
 
Spirometry

We are billing the spirometry with office visits and they are being denied as well, especially Medicare. Per Medicare Part B Issue 289 Oct 2013, "If a physician, in attendance for a pulmonary diagnostic procedure obtains a history and perfoms a physical examination related to the pulmonary diagnostic testing, separate reporting of an evaluation oand mangement serice is not appropriate. If a signficant, separately identifiable E&M serice is performed unrelated to the performance of the pulmonary diagnostic procedure test, an E&M service may be reported with modifier 25.

Then it goes on to state that if and E&M is billed without the modifier 25, the E&M will be denied.

What to do?
 
rhondareeney said:
Yes we are using the 25 modifier, they are bundling visits with the testing and paying the testing. We are having to appeal everything and get paid about 2 months out!!

I am wondering if I could can the 25 on the E/M, and use a 59 on the testing?
Click to expand...

You should only be using the 25 on the E/M, the description for modifier 25 is "Significant, separately identifiable evaluation and management service by the same physician............."
 
dclark7 said:
You should only be using the 25 on the E/M, the description for modifier 25 is "Significant, separately identifiable evaluation and management service by the same physician............."
Click to expand...

I agree with Doreen. There is NO WAY you should ever use 59 modifier on an E & M cpt code.Only a 25 modifier. For the coder who said two visits in one day(hospital and office). Insurances will only pay for ONE E & M per day. If they were both medically necessary you can appeal. They will deny them even with a 25 modifier but you should always appeal if they were medically necessary.When coders are coding services always ask yourself was this service medically necessary and if you can prove that to insurance you have a good chance of being paid.
 
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