preventative and and problem focused E&M

lgrabner

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The Colony, TX
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New to the physisican side of things. Peds wellness with a well documented prob focused E&M and a nebulizer treatment. I know the E&M should be billable with the 25 modifier. But, my claim is rejecting. Payer UHC. Diagnosis codes are appropriatly applied. Is this an error on their end or policy driven? What am I missing?
 

btadlock1

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Lubbock, TX
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New to the physisican side of things. Peds wellness with a well documented prob focused E&M and a nebulizer treatment. I know the E&M should be billable with the 25 modifier. But, my claim is rejecting. Payer UHC. Diagnosis codes are appropriatly applied. Is this an error on their end or policy driven? What am I missing?
You may need a 25 modifier on both E/M's, due to the nebulizer Tx. Here's what their policy on 2 E/M's says:
"Preventive Medicine services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, UnitedHealthcare will reimburse the Preventive Medicine service plus 50% of the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed."https://www.unitedhealthcareonline.com/b2c/cmaIndexResult.do?channelId=422fe7a1e193b010VgnVCM100000c520720a____&htmlFilePath=/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/ReimbursementPolicies/PMED_Prev Med_2012B.htm


Their policy on bundling edits (including a list of their edits), can be found here: https://www.unitedhealthcareonline....imbursementPolicies/REB_Rebundling_v2012A.htm

Good luck! ;)
 
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