Wiki Reimbursement for OV with a wellness exam

Create Wiki
T

tlwright70

Networker
Messages
30
Location
Muncie, IN
Best answers
0
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
 
Good Morning! Where are you placing the Mod. 25? on the Preventative (993xx) or the separate E/M (992xx)? And what dx code are you using on each E/M?

Jennifer
Coding Analyst
 
The modifier is going on the preventative code. The dx code is Z00.121 assigned to the 993xx and whatever the other dx are are assigned to the 992xx. We haven't had a problem with these until recently.
 
It will depend on the insurance company! There are a couple that do not allow the well and sick at the same time no matter what!
 
I have always put the 25 on the e&m code, not the preventative since its the lower RVU. That normally gets mine paid by the payers that will allow it. Some won't no matter what, esp some Medicaid MCO's but your commercial plans should cover it that way, providing your documentation supports it.

Sam
 
Hi,

Our office just uses 993xx for routine exams along with modifier 25, but for a 992xx is just for an office visit such as f/u or sick visits. Hope this helps.
 
I always put the modifier on the sick e/m code and that gets our sick with well claims paid every time.
 
You must log in or register to reply here.
Top