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Ultrasound incidental to E/M visit?

  1. #1
    Default Ultrasound incidental to E/M visit?
    Medical Coding Books
    I have started to received denials from payors regarding the following issue. Dr. does an ultrasound with a visit but the payor denies payment for the ultrasound stating it is "incidental to the primary procedure code" which was the E/M visit.

    Has anyone encountered this situation? How have you handled it? Are there new rules that I am not aware of?

    Any help is appreciated!

  2. #2
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    Tacoma, WA
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    1,087
    Default
    Quote Originally Posted by JLM322 View Post
    I have started to received denials from payors regarding the following issue. Dr. does an ultrasound with a visit but the payor denies payment for the ultrasound stating it is "incidental to the primary procedure code" which was the E/M visit.

    Has anyone encountered this situation? How have you handled it? Are there new rules that I am not aware of?

    Any help is appreciated!
    It is a diagnostic test and so should not be considered incidental, unless the reason for the visit was to have the ultrasound. We did have to start using modifier 25 on the E/M to show that it was a separate service on the same date of service in the case where a patient came for an evaluation and in the course of the visit it was decided to do an ultrasound. So the circumstances of the ultrasound do make a difference.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. Default
    May I ask what payer you received the denial and which payer you have to use the 25 modifier? Thank you!

  4. #4
    Default
    United Healthcare is denying the E/M code for payment. The patient came to our office for evaluation of LLQ pain and the doctor decided to do an ultrasound. Are there new rules out there? Does UHC not follow AMA guidelines?

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