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UHC denials on E&M codes...

  1. #1
    Question UHC denials on E&M codes...
    Medical Coding Books
    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!


  2. Smile 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

  3. #3
    Greeley, Colorado
    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 you will most likely need mod -59 on the spiro even if you don't bill the pulse ox.
    Lisa Bledsoe, CPC, CPMA

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