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E&M with Procedures being denied

  1. Default E&M with Procedures being denied
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    Hi there, I have recently received a Medicare audit denial for claims dating back to 2008 asking for their overpayment back on E&M visits billed with procedures. These were billed with a modifier 25 on the E&M and paid with no issue, now they are saying they are included. I have checked notes in the CPT manuals and on the software program we use by Ingenix and on that site it states these codes can be billed together. Did I miss an new guideling from Medicare that doesnt allow these to be billed together now? Are they going to audit all physicians for all these billings do you think? I am appealing this overpayment request and asking for a redetermination on all six of these claims, but I want to clarify for future, is there a way to know. Thanks!

  2. #2
    North Carolina
    It sounds as if Medicare has determined that the E/M was not a separate, identifiable service.

    Significant Evaluation and Management on the Day of a Procedure

    Modifier “-25” is used to facilitate billing of evaluation and management services on the day of a procedure for which separate payment may be made.
    It is used to report a significant, separately identifiable evaluation and management service by same physician on the day of a procedure. The physician may need to indicate that on the day a procedure or service that is identified with a CPT code was performed, the patient's condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed. This circumstance may be reported by adding the modifier “-25” to the appropriate level of evaluation and management service.

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