Revisiting Preventive with EM

ollielooya

True Blue
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900
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Everett, WA
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Here we go again....
Following up on AR sent to me by one of the major carriers with whom we have a contract.
99213-25 (272.0) denied as incidental to primary procedure
99396 (V70.0) paid
Q0091 (V76.47) denied as incidental to primary procedure
G0101 (V72.31) denied as incidental to primary procedure
93000 (V70.0)

Is the 99213-25 a legitimate denial? Provider relations wasn't that helpful other than to say we can't bill two EM codes and to go check out their editing policies at their web site. Really? It appears the preventive and problem related EM's have been paid in the past. Guess we're going to have to start asking the patients to reschedule their well visit exams if these denials will be a trend. Is an appeal in order? Missing modifiers? Advice, anyone?
 

kbarron

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Ossipee, NH
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some carriers will not pay for a "sick" visit with the Healthy visit. I would check what the contract says.
 

btadlock1

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Lubbock, TX
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Here we go again....
Following up on AR sent to me by one of the major carriers with whom we have a contract.
99213-25 (272.0) denied as incidental to primary procedure
99396 (V70.0) paid
Q0091 (V76.47) denied as incidental to primary procedure
G0101 (V72.31) denied as incidental to primary procedure
93000 (V70.0)

Is the 99213-25 a legitimate denial? Provider relations wasn't that helpful other than to say we can't bill two EM codes and to go check out their editing policies at their web site. Really? It appears the preventive and problem related EM's have been paid in the past. Guess we're going to have to start asking the patients to reschedule their well visit exams if these denials will be a trend. Is an appeal in order? Missing modifiers? Advice, anyone?
Who's the payer? I'd like to check out these 'editing policies'...
I'd say you're going to need to appeal with records, showing the extra work required to address the problem, and with copies of preventive service CPT guidelines, showing that you are supposed to bill problem E/M's separately.

The only problem you might encounter, here, is that your 'problem', is a chronic condition - unless there was a significant amount of work dedicated to the management (eg, if this was newly diagnosed, if the pt was experiencing worse-than-usual symptoms, or if labs were run, medication was changed, etc.), they might have an argument in saying that this was a relevant risk factor for the patient, and didn't require enough additional work to justify a separate E/M, in the first place. But that's just conjecture. Hope that helps! ;)
 

ollielooya

True Blue
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900
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Everett, WA
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Hmmmmm, thanks for the helpful info. It was a Regence claim, and now that you mention it I can see where it might not qualify for both EM visits due to the work significance of the sick visit. The guidelines do address this issue. Will summon chart notes, re-check policy and do what's prudent to determine next course of action. Thanks Brandi and Karen for jumping in!
 
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