Unbundling

Enubla

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Hello, I am trying to figure out how to bill the following charges? Which modifiers need to be on these charges? We billed with mod 25 on the 99214. Was advised by PPO insurance that 99396 and 90471 are bundling.

99214 25
99396
93000
90714
90471

Thank you!
 

unicorn80

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Neenah, WI
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First of all, if documentation supports 99396 then you would report it with the correct E/M code and modifier. After reviewing some other questions on the use of an E/M code with code 99396 it was stated that some insurances will not allow a preventive visit and regular E/M visit on the same day. So even if the components of a preventive visit and a regular E/M visit are stated in the documentation the claim may get denied as some payers will not allow this to be billed on the same day in one encounter.
 

mitchellde

True Blue
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13,391
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Columbia, MO
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First when you have a provider wanting a preventive and an office visit on the same day you must look to see if the provider discovered an new abnormality or exacerbation of an existing chronic issue. If you read in the CPC book this is when you have the premise of billing for both encounters. Then you need to see if the documentation actually supports both visit levels as distinct and separate levels of care. So do you have a preventive visit without using any components of the office visit and do you have an office visit without using any of the components of the preventive (chances are real good you do not), then IF you can meet the requirements then you can bill both levels and if there is an injection or other procedure you would need a 25 modifier on both.
If there is no problem discovered by the provider during a preventive, then you do not meet the requirements to bill both. If the patient presents with symptomatic complains or concerns and these are addressed then it is not a prevent encounter. read the Z00 description carefully it states visit without complaint.
 
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I came across where the patient came in for his annual physical 99396 which i billed out and insurance processed and paid. But then came in and recouped because on the same day he went upstairs to our specialty office under same tax id and that biller billed out 99214-25 with a procedure of OMT 98927. So insurance processed specialty office visit and procedure paid but recouped my 99396 physical in family medicine. I called trying to dispute stating that this is family practice and different from specialty but the rep said seeing that patient had a procedure which was (98927) that i couldn't bill that with physical. Can anyone help as to what i should do? or should I appeal. thank you
 

unicorn80

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Neenah, WI
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Rubybe

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Hello, I am trying to figure out how to bill the following charges? Which modifiers need to be on these charges? We billed with mod 25 on the 99214. Was advised by PPO insurance that 99396 and 90471 are bundling.

99214 25
99396
93000
90714
90471

Thank you!
A -59 on your admin code?
 
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