Wiki UHC denials on E&M codes...

[karlam]

We have been getting denials from UHC stating the OV is bundled into the pulse ox 94760 and spirometry 94150. I would think they would deny the tests and pay on the OV, but they didn't. They are saying we have to use -25 modier on the E&M. My CPT manual states that these codes exclude a separately identifiable E&M service, but it doesn't state to use the -25 modifier. I am missing something here?

Thanks for any input anyone can give!

Karla

 

[msmatiste]

CPT Codes 94060 & 94150 with an E/M Service

The AMA 2009 CPT Book states the following regarding these code, "Codes 94010-94799 include laboratory procedure(s) and interpretation of test results. If a separate identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported in addition to 94010-94799."

This means the use of modifier 25 is needed if indeed the E/M was a separate identifiable E/M Service.

"Modifer 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT Code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separetly, identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. (see Evaluation and Management Service Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptoms or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separetly identifiable non-E/M services, see modifier 59."

Key: The E/M Service was above and beyond the other service provided and that the documentation clearly satisfies the relevant criteria for the E/M Service in which the physician performed.

Source: American Medical Association's CPT 2009 - Professional Edition

 

[Lisa Bledsoe]

I agree in regards to using mod -25 on your E/M. I would not bother coding the pulse ox as it will be bundled into the E/M. You can code the spiro, though. UHC is unique in often requiring modifiers where we would not normally apply them, based on their own rules...so you will most likely need mod -59 on the spiro even if you don't bill the pulse ox.