Office visits

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Good afternoon all,
I am having an issue with getting E/M codes paid when I bill other codes on the same day for the same patient. I am at a loss trying to figure out what modifier to use or do I just stop billing the other codes so the doctor will get paid? I was using modifier 25 on all the visits but got an audit letter for the doctor. So I stopped billing with that, now none of the visits get paid. The other codes will get paid but not the E/M code. I am needing some help with this. Thank you all so much
 

Chelle-Lynn

True Blue
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Modesto, CA
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Can you give an example of the combination of codes you are billing that are problematic? Also is this a specific carrier you are having trouble with or multiple carriers?
 

dredmon

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Local Chapter Officer
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The Villages, FL
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office visit with a Z code

I have an E/M question as well i am being tole that I can not bill a Z01.30 code with an 99213 to medicare is this true? The patient came in for an office visit to have blood pressure checked for life insurance . the biller in my office will not submit the claim saying medicare will not take any Z code as primary. does anyone know of this?
 

Chelle-Lynn

True Blue
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Generally Medicare has specific rules in regards to preventative services. I would recommend that you use the Medicare Learning Network (MLN) for clear and specific guidelines for Wellness Services. Specifically "The Medicare Learning Network® (MLN) Preventive Services".

If the patient is being seen for a non-screening or sick visit, then you may need to look at using a more specific diagnosis other than Z01.30 as this is screening only.
 
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this is a typical charge for a doctor visit
99205 no modifier
97750 measurements were paid
97535 education was paid

99214 no modifier
29530 50 modifier paid
29540 50 modifier paid

Insurances Humana BCBS Aetna UHC
Pretty much all the insurances aren't paying the office visit if other codes are billed with it on the same day.
 

avon4117

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FLINT
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hmmm I would think the life insurance company will be responsible for paying that. I guess we have to understand that medicare is not going to pay for everything. Just let the patient know prior that medicare will not pay for that expense..you cannot use dx codes that are not applicable just so medicare will pay..thats fraud....either they will have to pay out of pocket or you simply cannot do it. This is in response to dredmmom
 
Last edited:

KMCFADYEN

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Roanoke, VA
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twilliams@lymphedemainstitute.org

99205, 97750 , 97535 do not seem to have any edits.
Perhaps Humana has an internal edit that bundles these?
Human has been known to do this. They will also use LCD's from other regions that do not apply to your region.

99214, 29530, 29540
I do see that 99214 needs modifier 25 to unbundle from 29530 and 29540 as long as documentation supports it.
 
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I would also agree that if the service is requested by the life insurance company, then they are the ones who should be responsible.

Medicare's policies make it very clear when they will or will not pay for services like this, and when a third party is involved, they will not pay for it. (With the exception of a subrogation-type/conditional payment situation that's applied to WC or liability).

As you described it, the sole purpose for the office visit is to complete work requested by the life insurance company, therefore no part of it would apply to Medicare, including the E/M charge. This isn't a screening, there's no medically necessary purpose for it, so trying to use a DX and modifier combo that gets Medicare to pay is indeed fraud.
 
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