Wiki Sequencing billing charges

[ollielooya]

Can I get some experienced eyes to survey this billing scenario and from a billing perspective offer insight into which way may correctly generate higher reimbursement?

1)
99213-25
17000
11100-59

OR

2) 99213-25
11100-59
17000

I realize the reimbursement is higher for the 11100 code than it is for the 17000 and that the higher amt should be placed first and even though both scenarios would yield payment, which one should be followed and the logic for doing so? And might the difference be substantial? Just wondering.....

 

[mzkandyd]

Hi ollielooya,

First and foremost...what is the reason for the encounter/procedure? This is where you would need to start(listing primary procedure first...behind the E/M)....I don't have your physician's notes in front of me but I would have to say that I would code it as follows without seeing it:

99213.25(sufficient documentation of course)
11100
17000.59 (documentation to support different anatomic sites).

I hope this helps!

-Kandy

 

[ollielooya]

Kandy, thank you so much for taking the time to reply, but my understanding is that the NCCI edits would require (if documentation properly supports) the assignment of modifier 59 to the component code of 11100. For clarities sake, let's suppose we had two different people with the same diagnoses that had the same insurance carrier plan and one was billed the first way and the other was billed the second way. Would both survive the audits and which one would yield higher return?

 

[mitchellde]

Suzanne,
You are correct in that the bundled code requires the modifier (as long as documentation supports. and we list the highest RVU procedure code first.
so assuming that the 11100 has the highest RVU and is the bundled procedure, then you would list the 11100-59 first followed by the 17000. We always list the E&M first that is just a cultural thing and it is expected that it will be done that way.
The payers are instructed to pay the highest listed RVU at 100% and discount the rest. However I think some programs are set to pay the first listed procedure (after the E&M) at 100% and discount the rest.
We are taught that we list the principle procedure first which should be the procedure that matches the principle dx code. This should be the most intensive procedure for the more intensive dx. MOST of the time the more intensive procedure is the one with the highest RVU since the RVU is suppose to match up to the "work" needed to perform the procedure. Sometimes this is not immediately obvious.