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Billing preventive service with problem e/m and a procedure

  1. #1
    Location
    Kansas City Chapter
    Posts
    33
    Default Billing preventive service with problem e/m and a procedure
    Medical Coding Books
    We had a 12 year old child present for preventive visit but also complaints of acne, warts and a chest problem. In addition to the preventive visit history and exam, the doctor diagnosed pectus carinatum, acne and warts, discussed the pectus carinatum and acne problem, wrote a rx for acne and removed the warts with cryosurgey. The physican wanted to charge the prevent as well as a level 2 e/m and the wart removal procedure, which we did attaching the -25 modifier to the level two visit. Insurance paid for the level 2 E/m and wart removal but not the preventive medicine code, stating "payment included in allowance for other service/procedure." Should we have used a different modifier because of the additional procedure done in order to get all services and procedures paid for? We normally have no problem getting both a preventive and problem visit paid for on the same visit so wondering if the procedure is what caused this preventive service to be "bundled" Any help would be appreciated!! THX!

  2. #2
    Default
    Quote Originally Posted by KERRIEA View Post
    We had a 12 year old child present for preventive visit but also complaints of acne, warts and a chest problem. In addition to the preventive visit history and exam, the doctor diagnosed pectus carinatum, acne and warts, discussed the pectus carinatum and acne problem, wrote a rx for acne and removed the warts with cryosurgey. The physican wanted to charge the prevent as well as a level 2 e/m and the wart removal procedure, which we did attaching the -25 modifier to the level two visit. Insurance paid for the level 2 E/m and wart removal but not the preventive medicine code, stating "payment included in allowance for other service/procedure." Should we have used a different modifier because of the additional procedure done in order to get all services and procedures paid for? We normally have no problem getting both a preventive and problem visit paid for on the same visit so wondering if the procedure is what caused this preventive service to be "bundled" Any help would be appreciated!! THX!
    If your patient was new, then I'd appeal the denial. Although I disagree with you e/m level (I would have given a 99213 due to the MDM), you're right about only needing a 25 on the problem e/m. But if your pt's established, then you'll need the 25 on both. Surgery global package has a guideline stating that if significant, separately identifiable e/m service is performed, report separately using 25 modifier. That includes prev. e/m as well. (However, new patient visit would be excluded from the global surgical package, because they haven't received services from that provider in at least 3 yrs...). I gather that your pt is established, though, by the fact that you received a denial, so I'd advise you to append the 25 to your denied code as well and send a corrected claim, if your documentation supports it.

  3. #3
    Location
    Kansas City Chapter
    Posts
    33
    Default
    Thank you very much Brandi - this was an est patient so we will use -25 on both visit

  4. #4
    Default Bundled per insurance
    You really should check with your individual contracts for the insurance. Even though it is defined in the CPT as not inclusive with a -25, some insurance carriers write it into the contractual agreements that they will not pay or will subject payment to carve-outs. We have a list in our office that enables us not spend time on denials that are never going to be reimbursable.

    Barbie Hays, CPC
    Coding Manager

  5. #5
    Default
    I agree with you Barbie, we have something similar in our practice. Check with your individual plans. I know that in Florida, Medicaid is a payer that does not pay for a well woman and a problem visit on the same day of service.

    Ivonne CPC, CPMA

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