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What Is Wrong?

  1. Question What Is Wrong?
    Medical Coding Books
    I am billing Medicare for Doctor of Osteopathy (DO) using 2 codes: E/M code99213 with modifier 25 and code 98926 - osteopathic manipulation. For many years we got payment for both codes. Suddenly, week ago I got payment only for code 98926 and zero for code 99213 wich was bundled with code 98926. What happened? And what can I do?

  2. #2
    Duluth, Minnesota
    Appeal it if you have supporting documentation. If you can show that the E/M is "significant separate identifiable". You should be able bill it with the .25 modifier along with the 98926.
    Donna, CPC, CPC-H

  3. Default
    I agree. You should appeal it. Maybe the carrier put some edits in place that kicked out your claims in error.

  4. #4

    I can't seem to log on to the CCI Edits webpage but have you looked your codes up there?

    If your second code is considered a component of the e/m code, it will require that you append a -59 modifier.

    Hope this helps!
    Sylvia Thompson, CPC
    Billing Supervisor
    San Diego, CA

  5. #5
    Modifier -25 indicates that a separately identifiable E/M
    service was performed on the same day as another independent procedure
    or service by the same physician. When a code from the special services,
    procedures and reports section is reported with an E/M service, Modifier
    -25 should not be appended to the E/M service, as the codes from the
    99000-99091 series do not describe separately identifiable services, but
    rather adjunctive services or circumstances that further describe the
    basic service rendered."

  6. Default Thanks, but question remains
    Thanks for all the feedback.
    Thank you, Sylvia for your reply. I know in the CCI Edits code (98926) is a component of the E/M code 99213. But does it require exactly modifier -59 or some modifier, in particular mod. -25? Now the issue of appending 59 vs 25 has come up. I think modifier -25 is more appropriate to use in this situation than a mod -59? I use mod. -25 with the code 99213 for many years and did not have any problems until now. OK, I will resubmit a claim with mod. -59 and will see what happen.
    Last edited by willlen; 07-25-2008 at 12:49 PM.

  7. #7
    Greeley, Colorado
    Just out of curiosity, did your Medicare carrier recently change? We have had a tremendous amount of problems since our carrier changed.

  8. Default
    Look at the narrative in the CPT book above the section that contains code 98926. It indicates that mod. 25 should be used on the E/M service. I would point to that in my appeal.

  9. #9

    Willen....cpt narrative does state that a same dos e/m would require a (-25) modifier. The only caveat I see is that in order to "unbundle" procedures (CCI), modifier (-59) is typically what is used on the "component code". I'm curious to see how your claim will process. Let us know!
    Sylvia Thompson, CPC
    Billing Supervisor
    San Diego, CA

  10. #10
    Kansas City, MO
    I just wanted to comment of the use of modifier -25 vs -59. Modifier -25 is used on E/M codes to seperate it from a procedure. Modifier -59 is used on procedure codes to seperate it from another procedure code. You should never append modifier -59 to an E/M code.

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