Wiki Unrelated EM performed within Global days of laceration procedure

[buuvaneisswaran]

I am having bit confusion over this scenario..

An established patient who had already received Laceration procedure[12011] and his insurance is BCBS HMO Plan.I verified that procedure 12011 has 10 days Global days.But within this global days the patient had returned to outpatient hospital settings and received I&D abscess drainage hand[10060] and EM [99214] by different physician. The EM performed now gets denial for being performed within global days.

Do i need to append Modifier 24.But Modifier 24 could be used when Unrelated EM service by same physician during postoperative period.Plz help me

 

[zafiro18]

This is also used when it is the same physician group. So if Dr. A and Dr. B are under the same Tax ID number, then they are looked at as the same physician "group" and you would need to append the modifier 24 to the E&M service.
The other solution is that if you are doing the I&D because of the original laceration, than the E&M is not billable, because this is an unfortunate procedure that is sometimes necessary and it is related to the original procedure.
However, the third solution is that the insruance company may be looking for a 25 or 57 modifier on the E&M because the I&D was performed on the same day.
My final suggestion is to call the insurance company and talk it out with them. They may want documentation stating that it is not related to the original procedure.

 

[buuvaneisswaran]

Thanks

I appended both Modifier 24,25 to EM and resubmitted the claim.thanks for the help

 

[Naveen Rachagolla]

In this case If iam not wrong code12001 has 000 as a global day and code 10060 has 10 day as global day,

you cannot append both Mods 24 and 25 not either of one , because the description for both mods clearly says by same physicians, in your case the patient is seen by different physician for I&D abscess.

If at all if the second procedure is because of the 12001 then i think you can bill 10060 with mod 77 and for this you cannot bill an EM service as it was already done in the previous visit by previous physician.

I hope this will give u some idea to some extent.

Will wait and see for others inputs also.
Naveen Rachaoglla
Client Policy Configuration Analyst.

I am having bit confusion over this scenario..

An established patient who had already received Laceration procedure[12001] and his insurance is BCBS HMO Plan.I verified that procedure 12001 has 10 days Global days.But within this global days the patient had returned to outpatient hospital settings and received I&D abscess drainage hand[10060] and EM [99214] by different physician. The EM performed now gets denial for being performed within global days.

Do i need to append Modifier 24.But Modifier 24 could be used when Unrelated EM service by same physician during postoperative period.Plz help me

 

[buuvaneisswaran]

Buuvaneisswaran

The Insurance states that the procedure is under Global Days.12011 procedure has 10 days Global period for that Insurance i stated above.The Modifier 25 is used to Differentiate the I&D Procedure and E/M performed on that day.However for a different procedure the previous physician's E/M documentation would not be considerable.So isn't it correct to code E/M for this visit???Please suggest me.

 

[Donna T]

I agree with Naveen. If the I&D was a complication from the original laceration then you can't bill an E/M service if the physician is from within the same group.