Wiki Reimbursement for OV with a wellness exam

[tlwright70]

Is anyone having problems with an OV (99212-99215) being paid when billed with a wellness exam. Modifier 25 was used with the dx being encounter for routine child health examination with abnormal findings and the diagnoses as secondary for the abnormal findings. Insurance denied the OV as being included in the payment for another service. Under appeal they upheld their denial stating separate reimbursement is not allowed for the lesser level E/M service code and providers should select a level of service representative of the combined services and submit the appropriate code for that level.

This is how we have been coding an OV with a preventative and have had no problems with reimbursement. Is anyone having this same issue and have any input?

Thanks,

Tina
CPC

 

[Jaime Weinand]

OV Dx s/b linked to OV CPT code

Hello,
From how I am understanding your post, you linked the office visit CPT code (99201-99215) to the preventative dx code of Z00.121. Is that correct? If so, the office visit CPT code should be linked to the diagnosis(es) as the reason for the separate & significant sign/symptom, condition or abnormal finding, e.g. otitis media, necessitating the OV. Modifier 25 would be attached to the office visit CPT code.

The preventative CPT code (99381-99395) should be linked to the primary diagnosis Z00.121 & diagnoses for example chronic conditions that are NOT addressed during the office visit. Screening lab diagnoses that are typically performed during the preventative exam would be linked to the preventative CPT code.

*Modifier 25 would be attached to the preventative visit CPT code if:
Developmental screening is done (96110)
And/or
If the payer is commercial, Medicaid patient over the age of majority (18 years in Nebraska), and CHIP when vaccine administration CPT codes are used (90471-90474 & 99460, 99461)—this as per Nebraska payer’s policy. Check with your State payer policies.

Hopefully, I understood your post, didn’t leave anything out, and was able to answer your question.
Thank you, Jaime