Wiki New patient E/M without the 25 modifier with a same day procedure?

[cert27388]

How do you handle Insurance companies that will not pay the 99203 on the same day as 31231 without the 25 modifier? Per NCCI edits the 25 modifier is not needed to separate from the procedure. However, the Insurance company denies as CO97 - global to the procedure. When we call to have them appeal....they tell us it needs the 25 modifier in order for them to pay. I don't want to put a 25 modifier on the 99203 just to get it paid--when the NCCI edits are telling me it does not need one. We have already appealed some of these denials 30 days ago with no response. If we wait too much longer then these claims will deny as past the filling limit. What is my recourse to have the Ins. Co. follow the NCCI edits?

 

[SharonCollachi]

Stop banging your head against a wall: The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents.

See also this AAPC article, which states, in part: In addition, commercial payers are NOT required to follow CMS guidelines and may set different limits or assign limits to codes not listed by CMS.