# what modifier



## southbaymed (Feb 15, 2011)

Please help me. 
Provider billed: 99215-25 99396, 90658, 90471-59, 82274, 92551,93000,94010,36415
except 99215, 90568, 90471, 94010, all other Cpt were for V70.0-routine physical.
Blue Shield denied 99396 saying included with 94010.
maybe need to add modifier. what modifer to be added to 99396??
we have another patient w/identical isuue which were never any problem before Sep.2010
thank you


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## mitchellde (Feb 15, 2011)

Why would you have a level 5 visit at the same time time as a preventive?  A level 5 is a very intensive exam and indicates patient that is definitely not well, while a preventive visit indicates a very well patient.  When you have performed the elements of a preventive exam, what is left that would constitute a level 5?  I have observed this being billed out before but I have never had the documentation support both.  Maybe you can append the documentation and we can review it for an opinion.


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## southbaymed (Feb 23, 2011)

thank you for your opinion and help.  I need the actual help to solve the bundling issue
of 94010 & 993.... seriese.  94010, although the majority carrier pay without requiring modifeir, a few (only I knew so far is Greatwest) deny the payment w/out modifier.
FYI, this Doc is 83 years old and still active to treat patient.  He is very trusted in our community bcz he listens patient's comment patiently.  He only sees 9-10 patients
betweek 9am-12.30 & 2p-530p (7hr operation). In thoses cases presented Q, he spends
about 100 minutes + his own time to document summarize his thoughts. BCZ he listens
patients he is finding more chornical ondition undermined.  So the ICD-9 codes he puts
are normally 7-8 and many critially chronic condition.  99215 & 9938seriese do not go together...we sees many comments in form of EOB; but for him, even with  high complexty condition, to do 993 serise is necessary to help & prevent further condition.

There is still doctor who is just listening and answering Q from patients sincerely.


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## gost (Feb 23, 2011)

Are you sure 94010 is the code they say it is included in?  Seems to me it should be mutually exclusive to 99215.  I would be curious to know who the payers are who are paying these two codes together.


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## eadun2000 (Feb 23, 2011)

southbaymed said:


> thank you for your opinion and help.  I need the actual help to solve the bundling issue
> of 94010 & 993.... seriese.  94010, although the majority carrier pay without requiring modifeir, a few (only I knew so far is Greatwest) deny the payment w/out modifier.
> FYI, this Doc is 83 years old and still active to treat patient.  He is very trusted in our community bcz he listens patient's comment patiently.  He only sees 9-10 patients
> betweek 9am-12.30 & 2p-530p (7hr operation). In thoses cases presented Q, he spends
> ...



I am going to venture out on here.  I doubt very seriously that a 99215 and 993 series would hold up in an audit.  It does not matter how much time he spends with the patient.   And you state that he listen's and finds more chronic conditions.... um is he actually treating these conditions?  I see absolutely NO justification for billing a 99215 and a preventative med code.  You state that he does the preventative med code because it is necessary to help and prevent a further condition.  I am so very confused.  Obviously if the patient is sick enough to warrant a 99215, which I find hard to believe, then the patient is way to sick for a preventative visit.  That is just the way it is.  You cannot code as a preventative just because you feel he goes over and above what he should do.  Same with a 99215.


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## mitchellde (Feb 23, 2011)

eadun2000 said:


> I am going to venture out on here.  I doubt very seriously that a 99215 and 993 series would hold up in an audit.  It does not matter how much time he spends with the patient.   And you state that he listen's and finds more chronic conditions.... um is he actually treating these conditions?  I see absolutely NO justification for billing a 99215 and a preventative med code.  You state that he does the preventative med code because it is necessary to help and prevent a further condition.  I am so very confused.  Obviously if the patient is sick enough to warrant a 99215, which I find hard to believe, then the patient is way to sick for a preventative visit.  That is just the way it is.  You cannot code as a preventative just because you feel he goes over and above what he should do.  Same with a 99215.



I so so so agree!  That is why I expressed this in the first place.  Thank you for laying it out beautifully.


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## eadun2000 (Feb 23, 2011)

mitchellde said:


> I so so so agree!  That is why I expressed this in the first place.  Thank you for laying it out beautifully.



LOL!  Wow Deb!  Score one for us!  We actually agree!!!! LOL


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## southbaymed (Mar 14, 2011)

I understand that both of you are experts of coding.  So, please help me the question I posted.  To which code 94010 is bundled.  

The biiling procedure codes you raised, I was able to talk with Dr. Eventhough, w/high complexty, MDM,situation, his philolosphy is not only with the pt's c/c points, but at the same time, by ckng overall body in whole help him for the future treatments.  This comes from his 55 some years professional experience and I cannot deny.
How about, it is not w/this forum topic, however, since there are many experts, please help.
He had pt who went to ER in wkend & apparently at ER nothing was found.(C/c was sudden
abodominal pain) Pt came (new pt....just FYI, many many his pts are who were not satisfied with their former Doc. & come to see him always bringing along with 10-20-30 years medical history), again the whole record from ER, he said it took 1/2 hour just to read and digest
and start pt's E/M. from which even he could not identified the cause of problem. He found
no abnomarlity; however took  him to conclude another 1/2 hour.  BCZ I brought two of your
comments to him, he wants to know what code he should bill???
 This is a medicare patient whoes medical history documentation is enormous.
Please help him
Thank you


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