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BCBS Denial of 99213-25 with 98940/98941

  1. #1
    Default BCBS Denial of 99213-25 with 98940/98941
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    I am New to Chiropractic billing and the provider is receiving denials for his established E/M visits when billed with a 98941-98942. New patient visits are paid with no issues, correct -25 modifier is being used, separate and billable diagnosis are used. Any suggestions?
    Thank you for any help!

  2. #2
    Upper Saddle River, NJ
    What is the reasoning for the denial? You must determine why they are denying it. If they contend it is due to a CCI edit use the following foundation for your appeal (see below). You can try to reach out to your provider representative with the Plan and alert them of this problem. You may be getting a electronic review of your claim and it does not recognize the modifier, request a manual review.

    I can say I see numerous inappropriate denials from this Plan and each must be appealed unfortunately.

    Good Luck !

    We are in receipt of your payment for the above referenced claim. However, it is our position that your company failed to reimburse properly for this treatment.

    This patient received an Evaluation and Management service on the same day that a procedure was performed. The claim was filed with the appropriate -25 modifier. This modifier, by definition, is to be used when a significant, separately identifiable evaluation and management service is provided by the same physician on the same day as a base procedure.

    It is our position that the E&M service was required to provide this patient with optimum care and should be fully compensated. Please reprocess this claim allowing benefits for the E&M service. If no additional benefits are released, we appreciate your written response to this appeal with supporting documentation from Correct Coding Initiate guidelines or any applicable internal policy guidelines.

  3. #3
    Default -25 delima
    You will continue to get denials as the E/M procedure is inside your manipulation. -25 has to show a separate issue outside the manipulation that you have performed. Think of it as the procedure comes with an E/M. Payers are cracking down on the misuse of -25.
    Sophia Alaniz, CPC

  4. Default
    Try adding 99213-25, 98941-AT

  5. #5
    Medical Billing
    Blue cross has a limit on established E&M by chiropractor, perhaps that is the issue. Massachusetts for example:

    Reimbursable only once per episode of care for the presenting condition or injury. Refer to Established Patient definition in the latest Current Procedural Terminology (CPT) annual edition. We may also reimburse a clinically indicated and medically necessary spinal manipulation on the same date of service, subject to the subscriber certificate.
    Last edited by CodingKing; 12-06-2018 at 09:39 AM.
    CRC (2018), CPC-P-A (2016), COC-A (2016), CPC-A (2015), PAHM (2010)
    Contract/Fee Specialist - Remote

    20 years health insurance experience: Audit, Claims, Customer Service, Payment Policy, Provider Relations, and Reimbursement

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