# 99204-25 + 93015



## amym (Aug 25, 2011)

I posted this in the billing forum but would like to get everyone elses opinion about this:

We have recently started encountering denials for CPT 99204-25 when billed same day as nuclear stress test 78452, 93015. The denial reason is "THIS PROC IS CONSIDERED INCIDENTAL TO ANOTHER PROC BILLED ON A HISTORY CLAIM". Is this accurate? We've never had this issue before. 

Is anyone else having this issue?  Are you appealing, writing off or have you changed the way tests are performed?

Thanks.


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## Jess1125 (Aug 25, 2011)

amym said:


> I posted this in the billing forum but would like to get everyone elses opinion about this:
> 
> We have recently started encountering denials for CPT 99204-25 when billed same day as nuclear stress test 78452, 93015. The denial reason is "THIS PROC IS CONSIDERED INCIDENTAL TO ANOTHER PROC BILLED ON A HISTORY CLAIM". Is this accurate? We've never had this issue before.
> 
> ...



The insurance might be bundling the testing into the E/M service which is wrong. I am having these appealed when they are bundling diagnostic testing into the E/M.

Jessica CPC, CCC


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## angelav@armedicalclaims.com (Aug 25, 2011)

*Appealing*

We've also had this problem since the new claim check edits that came out on 4/01/2011. We are appealing and getting paid. We are using modifier 25 on the E/M and 59 on the procedures, including both reports ie the office visit note and the echo or nuclear stress test report as well as copy of  2011 AMA CPT  code book page 5 in the Evaluation & Management section...it specifically states E/M and diagnostic test should be reported seperately. The edit is in  McKesson Claim Check so that's why some ins are denying and some are not. Hope this helps. ps There has been a letter sent from American Society of Echocardiography to McKesson about this issue, so hopefully that will help get the edit changed. AV


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## amym (Aug 25, 2011)

What about Medicaid claims, do a DMA520A?  Appeal on what basis, that they cannot be bundled together?


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## nessac2008@q.com (Aug 25, 2011)

Angela,
I'm trying to locate the statement that says "E/M and diagnostic testing should be reported separately". Which section on page 5 in the 2011 AMA CPT book. As I'm having the same problem as amym

Vanessa Charles


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## theresa.dix@tennova.com (Aug 26, 2011)

nessac2008@q.com said:


> Angela,
> I'm trying to locate the statement that says "E/M and diagnostic testing should be reported separately". Which section on page 5 in the 2011 AMA CPT book. As I'm having the same problem as amym
> 
> Vanessa Charles



Ok, on page 5 of the  evaluation and management service guidelines section under "levels of E/M services" the second column about 3/4 way down. The sentence starts with " The actual performance and /or interpretation of the diagnostic tests/studies........................... goes on to tell what was posted here.


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## amym (Aug 26, 2011)

I got a response from the billing forum that states the following: 

If the stress test was already scheduled, even if the patient is a new patient you cannot charge the visit level since the evaluation to determine the necessity for the procedure was already done, even if by another physician they are not inclined to pay for this twice. Rarely are tests like a nuclear stress test performed immediately after examining the patient, they are almost always scheduled ahead of time. If you have the rare instance where the provider is seeing the patient for the first time and makes a determination at that time a test is needed and it cannot wait to be scheduled then you can appeal with this information. 

Correct?


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## amym (Aug 30, 2011)

We now have Cigna denying all new patient codes when billed same day as 93015 or 78452.  Theresa, do you have a copy of that verbage you could send me?  I did not see that in the CPT Code book.


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