Results 1 to 4 of 4

payment for emergent care services 99058

  1. #1
    Location
    Everett, WA
    Posts
    886
    Default payment for emergent care services 99058
    Medical Coding Books
    Colleagues,
    This code has been discussed before as one that is not usually payable and bundled into an office visit. Ever so slowly we're seeing some of these pay. A major insurance company posted on one of their bulletins that they would recognize this code for payment beginning April 1 of last year. Up until this point they have made no payment, and today found out that the issue may be the need to add modifier 25. Patient presented to the office with no appointment for acute care, disrupting the normal office flow. Otherwise, they would have gone to the hospital. Doctor performed an E/M, then a procedure. We billed 99058 in addition. It was "bundled".
    Does modifier 25 really need to be added to this adjunct code? Is this a case of "carrier" specific guidelines and our being compliant to their billing requirements?
    ---Suzanne E. Byrum CPC

  2. #2
    Default
    Quote Originally Posted by ollielooya View Post
    Colleagues,
    This code has been discussed before as one that is not usually payable and bundled into an office visit. Ever so slowly we're seeing some of these pay. A major insurance company posted on one of their bulletins that they would recognize this code for payment beginning April 1 of last year. Up until this point they have made no payment, and today found out that the issue may be the need to add modifier 25. Patient presented to the office with no appointment for acute care, disrupting the normal office flow. Otherwise, they would have gone to the hospital. Doctor performed an E/M, then a procedure. We billed 99058 in addition. It was "bundled".
    Does modifier 25 really need to be added to this adjunct code? Is this a case of "carrier" specific guidelines and our being compliant to their billing requirements?
    ---Suzanne E. Byrum CPC
    99058 is a "special service" identifier CPT. It enhances Evaluation and Management and other physicians' service codes; it is not considered an E/M code. It would be inappropriate to append a 25 modifier to anything other than an E/M code, per CCI and CPT Guidelines. The guidelines make it pretty clear that 99058, as you've mentioned, is a secondary (dependant) code; it can't be reported without a primary service to enhance. That being said, as long as the primary service is significant and separately identifiable, the secondary service should be eligible for payment consideration, with no modifier required.

    Now, just because it doesn't need a modifier to be payable, doesn't mean that payers must cover it. Many don't. Take a look at this coverage policy by United Healthcare: https://www.unitedhealthcareonline.c...icies/AH_After Hours_v2011A.htm

    As long as they disclose their payment policy, they have a basis for denial. You can certainly try to appeal it, but you're facing an uphill battle. Nothing you change about the way that you billed it should make any difference, if the denial is correct. And if they are requesting special treatment, find every piece of literature you can that supports the way that you billed it, and appeal their unreasonable request. That would place an unnecessary hardship on your coders and billers, since all other payers recognize CPT guidelines and expect you to bill according to the standard rules - some patients are bound to be double-covered. Then what? Hope that helps!
    Last edited by btadlock1; 04-14-2011 at 08:45 PM.

  3. Default
    Our office bills the 99058 as tracking to keep abreast of how often this is happening to our schedule, we are infectious disease and also to let the insurance companies know it is out there and perhaps get on their fee schedule someday soon.

    Stephanie Thompson, CPC

  4. #4
    Location
    Everett, WA
    Posts
    886
    Default
    This was an old thread of mine and in looking back I was struggling with one of the major carriers in our area to issue reimbursement. They told us that our practice was the only one in the western region that had submitted a bill for this code. They eventually begin to pay, but then turned around and took back...I had worked over a year on getting this paid. Didn't get to push on with this scenario, but learned a lot from it. Practice moved to a bigger location and decided on-site billing would work best for them.
    Suzanne E. Byrum CPC
    Noridian
    NGS

Similar Threads

  1. Emergent Care Modifier
    By mcowper44 in forum Modifiers
    Replies: 2
    Last Post: 12-18-2015, 04:19 PM
  2. 25% payment reduction PC services for advance diagnostic imaging
    By chembree in forum Interventional Radiology
    Replies: 6
    Last Post: 02-07-2012, 02:07 PM
  3. 99058 and disruption of office services
    By ollielooya in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 09-16-2010, 03:11 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.