Wiki New Patient Office Visit Denials?

[sinman0531]

Hello,

I work for a dermatology office, and we are seeing a LOT of denials for new patient office visits when they are billed with *any* procedure--biopsy, premalignant destruction, malignant destruction, benign destruction....doesn't matter. It does seem to only be an issue when there are only a few diagnoses--for example a claim with B08.1, D48.5, X32.XXXA, Z80.1, Z80.9 the office visit might be denied as inclusive if we billed with a 11102.

Help?

 

[EricaPhl]

25 modifier?

 

[sinman0531]

25 modifier?

Our billing software automatically adds it on.

 

[SharonCollachi]

This is why we stopped doing procedures with evaluations. Some insurances won't pay, no matter what.

 

[sjooemmy08]

This is why we stopped doing procedures with evaluations. Some insurances won't pay, no matter what.

Agree. I told my doctor to stop doing the procedure with evaluation. Even Medi-Cal wouldn't pay for same-day eval+procedure

 

[mandymmathison]

Our practice refuses to let insurance companies control how we care for patients. The question is, is modifier 25 and the new patient office visit appropriate. Many procedures require the physician to evaluate the patient. If the patient was scheduled for that exact procedure ahead of time or referred by a PCP for that exact procedure there is no need for the office visit. An example would be podiatry and routine foot care for diabetics. The primary care physician oversees the patients condition and refers the patient for routine foot care. A physician already evaluated and determined the need for the procedure so it would be inappropriate for the podiatrist to bill and e/m that first visit if all they provide is routine foot care. The system automatically applying modifier 25 may be causing misuse of the modifier. These denials should be appealable if done properly and modifier 25 was correctly used. Our appeals include all the coding terminology stating please reconsider the new patient office visit as separately identifiable from example procedure. This new patient presented with a new unknown condition to Dr. X. After evaluating the patient Dr. X decided to do example procedure. Then include documentation pointing out how it's separate. If our claim recovery staff or the coder who submitted the claim isn't able to point out how its separate we query the physician for a letter to explain. It can be a lot of work but insurance companies shouldn't be controlling physicians or making procedures hard to schedule and inconvenience the patient with 2 visits if you're following the coding rules. Procedures with a 90 day global require modifier 57 versus 25.