Physical bundling with admin

kleger

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I am starting to recieve denials from an ins co when a patient has the following procedures: 99215/25, 99396, 90658, and 90471. They are paying the 99215/25, 90658 and the 90471 and dening the 99396. They state the 99396 is bundled with the 90471. Does the 90471 require a modifer 59 in order for it to go thru claims check? This has not been a problem in the past it has been occuring more so in the past couple of months.
 

dmaec

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WOW..! I would assume they would - I can't say that I've ever run across services where the patient has both a level 5 (99215) E/M AND a age specific preventive service at the same time! Usually when the provider marks a high level E/M and a preventive - after review of the chart notes it becomes apparent that the issues presented far outweigh the preventive service - usually resulting in an E/M charge only. Often, a preventive service will be charged with a low lever E/M (99212)... documentation supporting the E/M services that were above and beyond the preventive (usually something minor - sore throat, shoulder pain, etc) something that was addressed above the normal preventive.

that being said - if you truly have a level 5 E/M AND a preventive service, and documentation can stand alone to support BOTH services - along with the immunizations - you'd probably need a .25 modifier on both the preventive service (due to the immunizations) and on the E/M due to the fact that you have two service same day.

I'd be very interested in seeing the chart note for these services, I'd like to see documentation that actually supports both a 99215 and a preventive service.

just my opinion and having not seen the documentation - I'm thinking this should be a 99215.25 only (no preventive service charged) OR a lower level E/M, dx specific, linked accordingly along with the preventive. mods on both services if both services are supported - and immunizations linked accordingly as well....
 
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