Wiki Over Coding Issue

Create Wiki
S

Sammedyann@gmail.com

New
Messages
2
Location
Candler, NC
Best answers
0
Hi Everyone,

I've recently started a new position with a family planning clinic and I'm the first coder they've ever had. The previous billing supervisor, who is no longer with the company, put a rule in place that all procedures should be billed with an E/M code & modifier 25. As we all know E/Ms shouldn't be billed with surgical services unless there is a separately identifiable reason. This rule has been in place for approximately 2 years and our predicament is what to do about the over-payment from the insurance companies. Has anyone run into this in the past? How did your organization handle it? Thank you for any input!
 
Modifier 25 on Eval Mgmnt

Some payers are now reducing the payment if the modifier 25 is used or placed on the office visit. When a patient has a routine problem for the returning patient adding a modifier 25 for a routine lab test gets a reduction. Such as the dx code is DM and patient gets a finger stick. Do not add modifier 25 to this scenario. Or the patient has UTI dx. and the urine lab test is added they old way was use to add modifier 25 . At this time do not add modifier 25 unless want a lower payment . Things change all the time. You may want to contact your individual payers. Now a office visit may required lab and injections to be ordered by physician to determine their level of illness or specific bacteria. It can be justified. then I would add a modifier 25. Injections still add modifier 25 or certain blood work add modifier 25 if done same date as office visit. Also you may want to create a coding protocol for your office to help guide you.

And if patient needs skin lesion/skin tag removal during same as office visit I would add modifier 25. However if the patient has had a previous appointment schedule to return just to do mole skin tag removal just charge for the clinical procedure done for the day not the office visit/evaluation management too.

Hope this information helps you

T.
 
Identifying a past billing error is actually a fairly common occurrence, and if it is has been determined that the error has caused overpayments, then it is the practice's responsibility to correct the claims and return the payments promptly - there really isn't any other options for a proper way to handle this.

The first step here would be to start sampling some documentation and determine the extent to which this procedure has caused overpayments. An E&M with a modifier 25 does not necessarily have to have a 'separately identifiable reason', but rather, requires that a "significant, separately identifiable service is also performed", so a review of individual notes will be required to know for sure how many of these E&M codes are really inappropriate - assuming that all of these are incorrect would be as much as mistake as the previous supervisor's assumption that they were always allowed. If possible, you may wish to get input from a consultant auditor who has advanced understanding of E&M coding and payer audits as to which services are defensible and which not.

But if in fact you determine that there have been services billed and paid in error, your practice should act quickly on this. For government payers, you are now under a strict time limit to get the refunds sent back so claims for those payers should be the first priority. For commercial plans, you may wish to refer to your contracts or speak to your payer representatives to work out the best way to go about getting the incorrect claims fixed and the payments sent back or recouped. Depending on the size and extent of the problem, they may be willing to work with you to make a settlement or take the repayments in installments, and they may be able to help facilitate the adjustment process by handling it as a special project rather than sending in each claim individually which could become very time-consuming. And of course, any patient payments taken for services not rendered will also need to be credited back to those patients' accounts.

Hopefully you have notified your practice manager and/or compliance officer and they will work with you on this to get the guidance and resources you need - if this ends up being a large undertaking, or if it has the potential to have a significant impact or cause disruption in cash flows, then it's definitely not something that a coder or biller should undertake independently or without the participation of management.
 
Last edited:
Thomas Field is 100% right about commercial carriers. I work for a small carrier, and we deal with this all the time. If you approach us, versus us catching you, we are much more willing to work with you. I mean, we might not have ever caught it, or it may have taken us years. My employer(and the other employers I've worked for previous to this one.) Is much more willing to set up a special project, let you make payments instead of demanding a bulk payment or possibly even settling if you tell us versus us catching you. ALso something Thomas didn't mention, if you self report and you're and in network provider, it's highly unlikely we terminate your contract. If we catch you... there's a high likelihood that we either terminate your contract immediately or decline to renew it after the renewal date.
 
You must log in or register to reply here.
Top