Wiki payment for emergent care services 99058

[ollielooya]

Colleagues,
This code has been discussed before as one that is not usually payable and bundled into an office visit. Ever so slowly we're seeing some of these pay. A major insurance company posted on one of their bulletins that they would recognize this code for payment beginning April 1 of last year. Up until this point they have made no payment, and today found out that the issue may be the need to add modifier 25. Patient presented to the office with no appointment for acute care, disrupting the normal office flow. Otherwise, they would have gone to the hospital. Doctor performed an E/M, then a procedure. We billed 99058 in addition. It was "bundled".
Does modifier 25 really need to be added to this adjunct code? Is this a case of "carrier" specific guidelines and our being compliant to their billing requirements?
---Suzanne E. Byrum CPC

 

[btadlock1]

Colleagues,
This code has been discussed before as one that is not usually payable and bundled into an office visit. Ever so slowly we're seeing some of these pay. A major insurance company posted on one of their bulletins that they would recognize this code for payment beginning April 1 of last year. Up until this point they have made no payment, and today found out that the issue may be the need to add modifier 25. Patient presented to the office with no appointment for acute care, disrupting the normal office flow. Otherwise, they would have gone to the hospital. Doctor performed an E/M, then a procedure. We billed 99058 in addition. It was "bundled".
Does modifier 25 really need to be added to this adjunct code? Is this a case of "carrier" specific guidelines and our being compliant to their billing requirements?
---Suzanne E. Byrum CPC

99058 is a "special service" identifier CPT. It enhances Evaluation and Management and other physicians' service codes; it is not considered an E/M code. It would be inappropriate to append a 25 modifier to anything other than an E/M code, per CCI and CPT Guidelines. The guidelines make it pretty clear that 99058, as you've mentioned, is a secondary (dependant) code; it can't be reported without a primary service to enhance. That being said, as long as the primary service is significant and separately identifiable, the secondary service should be eligible for payment consideration, with no modifier required.

Now, just because it doesn't need a modifier to be payable, doesn't mean that payers must cover it. Many don't. Take a look at this coverage policy by United Healthcare: https://www.unitedhealthcareonline....taticFilesHtml/ReimbursementPolicies/AH_After Hours_v2011A.htm

As long as they disclose their payment policy, they have a basis for denial. You can certainly try to appeal it, but you're facing an uphill battle. Nothing you change about the way that you billed it should make any difference, if the denial is correct. And if they are requesting special treatment, find every piece of literature you can that supports the way that you billed it, and appeal their unreasonable request. That would place an unnecessary hardship on your coders and billers, since all other payers recognize CPT guidelines and expect you to bill according to the standard rules - some patients are bound to be double-covered. Then what? Hope that helps!

 

[MLenz]

Our office bills the 99058 as tracking to keep abreast of how often this is happening to our schedule, we are infectious disease and also to let the insurance companies know it is out there and perhaps get on their fee schedule someday soon.

Stephanie Thompson, CPC

 

[ollielooya]

This was an old thread of mine and in looking back I was struggling with one of the major carriers in our area to issue reimbursement. They told us that our practice was the only one in the western region that had submitted a bill for this code. They eventually begin to pay, but then turned around and took back...I had worked over a year on getting this paid. Didn't get to push on with this scenario, but learned a lot from it. Practice moved to a bigger location and decided on-site billing would work best for them.