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Thread: Denial For 99212-25

  1. #1

    Arrow Denial For 99212-25

    I received a Denial from Superior Health Plan. This was a ThSteps Exam along with an office visit. 99393-AM with V20.2. 99212-25 with 477.9. 99212 was denied because :"PROCEDURE CODE UNBUNDLED FROM GLOBAL PROCEDURE CODE". Cannot figure why that is? I am a new coder, if you can help me out with this?

  2. #2

    Default

    I do not see anything that is incorrect in your coding. The only thing would be if your pt had any type of procedure during the previous 90 days that would have a global - if so then you would have to add a mod to your e/m to get it paid if it had nothing to do with that procedure

  3. #3
    Join Date
    Apr 2007
    Location
    Hartford, CT
    Posts
    721

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    An exam has to be "significant, separately identifiable" to use the 25 modifier. Verify with your provider relations, the insurance may not consider the work done for a 99212 to be significant or separate. Even CPT states that the problem has to be significant enough to require additional work to perform the key components of a problem oriented E/M. CPT also states that an insignificant or trivial problem.....that does not require additional work up should not be reported. Check the documentation, was a separate exam done, were tests ordered? If the work for th
    Doreen Clark, CPC, CPMA
    Medical Auditing Specialist
    Integrated Physicians Management Services
    East Harftord. Ct

  4. #4
    Join Date
    Apr 2007
    Location
    Austin
    Posts
    5

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    Hi, I deal with SHP all the time and 477.9 is not a justifible dual visit. You add it on with the Preventative visit. There is usually not enough documentation outside of the WCC to justify a seperate visit. Allergic Rhinitis: Bill dual if Lab work/s[ecimen or referral is needed of significant counseling is done.

    An insignificant or trival problem or abnormality that is encountered in the process of performing the Preventative medicine Evaluation which does not require add'l work and performance of the key components of a problem-oriented E/M should not be reported.

    The key to adding an E/M service to the preventative visit is the significance of the problem, the amount of work required to deal with the problem and how clearly it is documented in the pt's chart.
    Kelly L Salerno, CPC

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