# Same day, billing office visit and procedure on separate claims.



## JesseL (Dec 22, 2018)

Currently, Healthfirst NY is doing something stupid and denying all E&Ms billed with a minor procedure even THOUGH there's a modifier 25 on the E&M.  We use modifier 25 appropriately so its not as though we're abusing it.

I tried talking to Healthfirst but it's like talking to a wall when you're trying to dispute the claim with them that the E&M shouldn't be denied because of the modifier 25.

I suspect it's a system error on their end because they use to deny a claim entirely if there's any j codes billed on the claim like J3301.  To avoid denials, I just bill the injection, 11900, on one claim and then make another claim for the J3301 and that prevented the claim from getting denied.

I did a test claim and billed 99203-25 on one claim and 11100 on another for the same date of service, in the end this creates two separate claim numbers but no longer getting global denials for the 99203-25.

My question is, is there any problems in doing this?  Splitting the office visit on one claim with modifier 25 and billing the procedure on another claim, for the same service date of course.


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## Rajinder_Dhammi (Jan 24, 2019)

*Not at all*

I see no problem doing that.

I work for an optha specialist and many times we bill an E&M along with modifier 57 with diagnostic studies on one claim and on a separate claim, we bill a surgery code for same DOS and we get paid as well.

Thank you,
Rajinder Singh Dhammi, CPC


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## CodingKing (Jan 24, 2019)

purposely splitting claims to get around a payer payment policy would fall under the umbrella of fraud waste and abuse. misrepresentation to get undue payment. My PCP used to do that to get around to get around 50% reduction on E&M w/ preventive. Insurance took back funds once it was discovered and terminated the contract.


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## thomas7331 (Jan 24, 2019)

I agree with CodingKing - this is not the right way to go about resolving the issue.  Payers catch on to provider billing patterns and if they are intentionally denying this in accordance with their policies, then they will likely figure out what you are doing and recover the payments at a later date.  

I would escalate this with your payer, painful as that may be.  If in fact this is an error on their part, it needs to be brought to their attention.  Speak to your provider rep and if they agree that this should not be happening and will give you the OK in writing to split the claims until they can make a correction, then that would be fine.  I would not recommend just initiating this process unilaterally.


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## JesseL (Jan 29, 2019)

thomas7331 said:


> I agree with CodingKing - this is not the right way to go about resolving the issue.  Payers catch on to provider billing patterns and if they are intentionally denying this in accordance with their policies, then they will likely figure out what you are doing and recover the payments at a later date.
> 
> I would escalate this with your payer, painful as that may be.  If in fact this is an error on their part, it needs to be brought to their attention.  Speak to your provider rep and if they agree that this should not be happening and will give you the OK in writing to split the claims until they can make a correction, then that would be fine.  I would not recommend just initiating this process unilaterally.



The thing is, talking to the provider rep and phone rep are both like talking to the wall.  I'm still trying to get this resolved through our IPA.

No matter who I talk to from healthfirst, our provider rep included, gives the following response:

"According to our policy, when an Evaluation and Management service is billed with modifier 25 on the same day as a procedure with a 0-day, 10-day, or 90-day postoperative period, the Evaluation and Management service is payable only if it is significant and separately identifiable. Therefore, if the patient has had a previous face-to-face visit for the same or similar diagnosis as the Evaluation and Management service with modifier 25 and the procedure, then the Evaluation and Management service billed with modifier 25 will be denied."

Their "therefore" explanation doesn't make sense or summarize their definition of modifier 25.  It looks like they're talking about modifier 24, which they've also been denying for years..

I don't know what the hell is going on with them and talking to healthfirst only drives me insane because they give me that same response that they can't admit doesn't make sense and talking to our provider rep is just as useless because she has 0 knowledge about billing.


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## thomas7331 (Jan 30, 2019)

Actually, the policy language you've cited does sound like they're talking about modifier 25, although I don't agree with the rationale.  If a problem was evaluated at a previous visit, and the patient returns with that same problem and has a procedure done and there is no new problem and no change in condition from the prior visit, then there shouldn't be an E&M visit billed with a modifier - evaluations of a problem on the same day are included in the reimbursement for a procedure per almost every payer's policy, with the exception of 90-day procedures, in which case it should be modifier 57 instead.  But I disagree with this payer, though, because you can't make this determination solely from the diagnosis or the claim history - this requires a record review.  But at the same time, having worked for payers, I understand their position because there is a lot of abuse of modifier 25 and many providers simply charge an E&M for every visit with a procedure, whether or not the modifier is supported.  Some payers find that the problem is so widespread that they unfortunately take the approach of the providers being 'guilty until proven innocent' and deny every instance.  Have you sampled these denials and reviewed your provider's documentation to validate that these modifier are in fact appropriately assigned and the E&M service documented in these cases is clearly not part of the global package of the procedure?  

I hear your frustration though and have been there too.  But unfortunately, dealing with payer policies and bureaucracy is something all practices have to deal with - there's no escaping this.  There are some strategies you can try.  If this is a minor problem, then you can write these off as the cost of doing business, but track the amounts to show them the cost and use it as a bargaining chip to argue for a rate increase next time your contract is reviewed.  If the problem is larger, you can, within the limits of your contract and in consideration of the impact on your practice and patients, withdraw or threaten to withdraw from the network.  A formal letter from your practice manager or attorney to your network representative stating your intention to leave the network is almost certain to get their attention and bring them to the table to talk.  Alternatively, you can just start appealing these.  Create a template appeal letter tailored to this specific issue, set up a streamlined process, and send every one of these in for review.  If they are not overturned, then escalate every one.  Appeals are costly to payers, and sometimes the only way to make them understand that they have a bad policy is simply to swamp them with appeals and create enough work for them that they come to understand it isn't in their interest to continue the practice.  

In any case, there's no value to letting it get under your skin.  This is all part of the job and if you work with your practice leadership, and tackle it with determination, creativity, persistence and strategy, you can be successful in this over the long run.


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## MARYELLENG (Jan 30, 2019)

Medicare denied a 99214 mod. 25 with 77263/77334/77290. when we called they informed us we had to use an unbundling code but not modifier 25. We always got paid in the past with the 25 modifier. I cant find anything new on Medicare website.


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## JesseL (Jan 30, 2019)

thomas7331 said:


> Actually, the policy language you've cited does sound like they're talking about modifier 25, although I don't agree with the rationale.  If a problem was evaluated at a previous visit, and the patient returns with that same problem and has a procedure done and there is no new problem and no change in condition from the prior visit, then there shouldn't be an E&M visit billed with a modifier - evaluations of a problem on the same day are included in the reimbursement for a procedure per almost every payer's policy, with the exception of 90-day procedures, in which case it should be modifier 57 instead.  But I disagree with this payer, though, because you can't make this determination solely from the diagnosis or the claim history - this requires a record review.  But at the same time, having worked for payers, I understand their position because there is a lot of abuse of modifier 25 and many providers simply charge an E&M for every visit with a procedure, whether or not the modifier is supported.  Some payers find that the problem is so widespread that they unfortunately take the approach of the providers being 'guilty until proven innocent' and deny every instance.  Have you sampled these denials and reviewed your provider's documentation to validate that these modifier are in fact appropriately assigned and the E&M service documented in these cases is clearly not part of the global package of the procedure?
> 
> I hear your frustration though and have been there too.  But unfortunately, dealing with payer policies and bureaucracy is something all practices have to deal with - there's no escaping this.  There are some strategies you can try.  If this is a minor problem, then you can write these off as the cost of doing business, but track the amounts to show them the cost and use it as a bargaining chip to argue for a rate increase next time your contract is reviewed.  If the problem is larger, you can, within the limits of your contract and in consideration of the impact on your practice and patients, withdraw or threaten to withdraw from the network.  A formal letter from your practice manager or attorney to your network representative stating your intention to leave the network is almost certain to get their attention and bring them to the table to talk.  Alternatively, you can just start appealing these.  Create a template appeal letter tailored to this specific issue, set up a streamlined process, and send every one of these in for review.  If they are not overturned, then escalate every one.  Appeals are costly to payers, and sometimes the only way to make them understand that they have a bad policy is simply to swamp them with appeals and create enough work for them that they come to understand it isn't in their interest to continue the practice.
> 
> In any case, there's no value to letting it get under your skin.  This is all part of the job and if you work with your practice leadership, and tackle it with determination, creativity, persistence and strategy, you can be successful in this over the long run.



The e&ms being denied all have different diagnoses from the procedure because they are truly unrelated to the procedure.  The e&m are all getting denied with modifier 25 regardless of the diagnosis.  I never had a successful appeal with this payer (for the past year) for any reason because they have a system where they deny everything, no joke.  The responses are generally generic and sometimes have nothing to do with the appeal.  They even told me the phone reps are no longer allowed to send claims back for review on their end and that I have to go through their dead end appeal process.

Doubt my boss would be willing to threaten to withdraw from the network (that benefits them anyway) but i do think she should sue them.  We are already struggling due to pay cuts from commercial payers so leaving a network where most of our patients are in is the last thing she’d want to do.


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## JesseL (Feb 6, 2019)

thomas7331 said:


> Actually, the policy language you've cited does sound like they're talking about modifier 25, although I don't agree with the rationale.  If a problem was evaluated at a previous visit, and the patient returns with that same problem and has a procedure done and there is no new problem and no change in condition from the prior visit, then there shouldn't be an E&M visit billed with a modifier - evaluations of a problem on the same day are included in the reimbursement for a procedure per almost every payer's policy, with the exception of 90-day procedures, in which case it should be modifier 57 instead.  But I disagree with this payer, though, because you can't make this determination solely from the diagnosis or the claim history - this requires a record review.  But at the same time, having worked for payers, I understand their position because there is a lot of abuse of modifier 25 and many providers simply charge an E&M for every visit with a procedure, whether or not the modifier is supported.  Some payers find that the problem is so widespread that they unfortunately take the approach of the providers being 'guilty until proven innocent' and deny every instance.  Have you sampled these denials and reviewed your provider's documentation to validate that these modifier are in fact appropriately assigned and the E&M service documented in these cases is clearly not part of the global package of the procedure?
> 
> I hear your frustration though and have been there too.  But unfortunately, dealing with payer policies and bureaucracy is something all practices have to deal with - there's no escaping this.  There are some strategies you can try.  If this is a minor problem, then you can write these off as the cost of doing business, but track the amounts to show them the cost and use it as a bargaining chip to argue for a rate increase next time your contract is reviewed.  If the problem is larger, you can, within the limits of your contract and in consideration of the impact on your practice and patients, withdraw or threaten to withdraw from the network.  A formal letter from your practice manager or attorney to your network representative stating your intention to leave the network is almost certain to get their attention and bring them to the table to talk.  Alternatively, you can just start appealing these.  Create a template appeal letter tailored to this specific issue, set up a streamlined process, and send every one of these in for review.  If they are not overturned, then escalate every one.  Appeals are costly to payers, and sometimes the only way to make them understand that they have a bad policy is simply to swamp them with appeals and create enough work for them that they come to understand it isn't in their interest to continue the practice.
> 
> In any case, there's no value to letting it get under your skin.  This is all part of the job and if you work with your practice leadership, and tackle it with determination, creativity, persistence and strategy, you can be successful in this over the long run.



So you are also saying that if we saw a patient for psoriasis a month ago and then the next time the patient came to follow up on the psoriasis and has a wart, we used liquid nitrogen to destroy wart and also examined the patient's psoriasis, we don't get credit for examining the psoriasis with modifier 25 just because it was evaluated before?


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## thomas7331 (Feb 6, 2019)

JesseL said:


> So you are also saying that if we saw a patient for psoriasis a month ago and then the next time the patient came to follow up on the psoriasis and has a wart, we used liquid nitrogen to destroy wart and also examined the patient's psoriasis, we don't get credit for examining the psoriasis with modifier 25 just because it was evaluated before?



No, I said nothing of the sort; I'm sorry if it was not clear.  I am just restating the information from the global surgery rules that the evaluation of a problem that it treated with a minor procedure is included in the reimbursement for that procedure.  So if a wart had been evaluated at a previous visit, and then that (same) wart was treated with a minor procedure at the next visit, with no change in condition in the interim that would require re-evaluation, then the modifier 25 would not be supported.  But if there are other problems being addressed, then the E&M directed at those may be considered separately identifiable.  But as I also said, the only way to determine whether or not the codes and modifiers are truly supported is by a record review.


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## JesseL (Feb 6, 2019)

thomas7331 said:


> No, I said nothing of the sort; I'm sorry if it was not clear.  I am just restating the information from the global surgery rules that the evaluation of a problem that it treated with a minor procedure is included in the reimbursement for that procedure.  So if a wart had been evaluated at a previous visit, and then that (same) wart was treated with a minor procedure at the next visit, with no change in condition in the interim that would require re-evaluation, then the modifier 25 would not be supported.  But if there are other problems being addressed, then the E&M directed at those may be considered separately identifiable.  But as I also said, the only way to determine whether or not the codes and modifiers are truly supported is by a record review.



Thank you for clarifying!

But that is what is happening to us right now.

Healthfirst is denying all follow up office visits billed with a modifier 25 (or any claim billed with a diagnosis code that has been billed in previous visits)  on the same day as a procedure that is UNRELATED to the procedure.  The scenario that I stated with the follow up psoriasis and treatment of new warts, healthfirst is denying the follow up based on their rational of "if the patient has had a previous face-to-face visit for the same or similar diagnosis as the Evaluation and Management service with modifier 25 and the procedure, then the Evaluation and Management service billed with modifier 25 will be denied."  I submitted so many appeals to them that I can tell no actual person is reviewing them because 100% of any appeals I sent them gets denied automatically.  Escalating them only results in more denials.  Their responses are never straight answers as to why they are denying our specific claim other than their generic response of THEIR definition of modifier 25.  There's so many denials that I honestly can't keep up with them.


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## medicalauditor (Feb 13, 2020)

CodingKing said:


> purposely splitting claims to get around a payer payment policy would fall under the umbrella of fraud waste and abuse. misrepresentation to get undue payment. My PCP used to do that to get around to get around 50% reduction on E&M w/ preventive. Insurance took back funds once it was discovered and terminated the contract.


I agree. Splitting claims to get around payer denials is not ok.


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