Pediatric Behavioral Health

1Woodhealth

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Hoping for some feedback from anyone that bills out incident to under the physicians name for OT, PT, SLP. Our office has what they reference as a "team day" the doctor does an E/M and bills out according to time spent. She then collaborates with the therapists and they are billing out the individual therapist codes of 97001, 97003, 92523 also under the physicians names. In addition to these they tend to bill out for the 96111. These are long, and well documented assessments and E/M services, usually the patient is in the office for a total of 4 hours. We are getting random bundled denials from payers such as Anthem, who may pay all of the service items for one patient and then deny out either the 97003 or the 96116 as a bundled service. We are billing out with the 25 modifier to separate out the CCI edit issue between the E/M and 96116, there are no more edits between the other code combinations. Thank you for an input you can give.:confused:
 
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Hoping for some feedback from anyone that bills out incident to under the physicians name for OT, PT, SLP. Our office has what they reference as a "team day" the doctor does an E/M and bills out according to time spent. She then collaborates with the therapists and they are billing out the individual therapist codes of 97001, 97003, 92523 also under the physicians names. In addition to these they tend to bill out for the 96111. These are long, and well documented assessments and E/M services, usually the patient is in the office for a total of 4 hours. We are getting random bundled denials from payers such as Anthem, who may pay all of the service items for one patient and then deny out either the 97003 or the 96116 as a bundled service. We are billing out with the 25 modifier to separate out the CCI edit issue between the E/M and 96116, there are no more edits between the other code combinations. Thank you for an input you can give.:confused:

96116 and 96111 both include the exam, interpretation, and report, all which must be done by the same person. Because these services are diagnostic, they can't be incident-to. If the doctor did not perform the exam, interpretation, and report, you cannot bill under their name. So using the example of an E/M and 96116 being billed under the doctor's name, adding the 25 modifier may break the edit, but it would be improper to do so. It's not a CCI issue, it's an issue as to who did what and what can be considered incident-to. Also, certain payers have rules regarding what type of provider they will pay for a specific service and these vary across the board.

97001, 97003, and 92523 can raise flags if billed under the doctor's name because each code eludes to a certain type of therapist (PT, OT, SLP). If a claim is billed under the doctor's name, the payer may ask why the doctor is performing physical therapy services, for example.

The other thing you should take a look at is the diagnosis code being used. For example, a patient is seen for memory problems and so forth. The doctor does an office visit and makes a diagnosis of dementia. If the patient is then seen by another provider, but is incorrectly being billed under the doctor's name, for a neurobehavioral status exam (96116), it would be medically unnecessary for the subsequent exam if the doctor has already made a diagnosis. Basically it's two exams for the same CC on the same day under the same doctor's name.

Varying diagnoses may also be contributing to the denials as some payers have specific diagnoses that must be used in order to receive a particular service. A patient's age could even cause denials depending on payer policy.
 
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