# BCBS denying E/M codes with 25 modifier



## melissa0414

I do billing for five different practices across Texas and am having an issue with BCBS.  They are denying most E/M codes when we use the 25-modifier (to distinguish from other services rendered the same day).  I've gotten dozens of these so far.  I have read some info online from different practices that BCBS is going to reduce reimbursement on E/M's when billed with the 25-modifier to 50% of the allowed amount.  But I haven't seen anything in black and white from BCBS itself.  Does anyone have any hard information on this change?  The dozens of appeals are KILLING me.  Maybe I shouldn't have taken on five practices.


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## adawson5

I have a practice that just received denials of E/M with the -25 modifier.  BCBSTX is useless!  

I've also recently gotten denials for charges with the -59 modifier.  I have resolved some of them, but haven't figured out some.

I guess I will get to writing appeals.


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## HLD23MPC 

I do the billing for an Urgent Care in Rhode Island and mostly the BCBS billing. Instead of modifiers 59 use XU & XS and always make sure those are on any 9 codes and mod 25 is on E&M.


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## HLD23MPC 

Also do you have to write an appeal. Can't you just send a corrected claim electronically through your softawre? Usually it is just using an extended ailment and making sure the ICN # is showing up in your system


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## wright3709@yahoo.com

*Reimbursement*

I don't know specifically what you are coding, but here is a link regarding Anthem and it states dates of service starting 1.1.18 E/M services eligible for separate reimbursement for minor surgeries will be reduced by 50%. 

http://www.cmanet.org/files/assets/news/2017/11/anthemmckessonchanges-1-1-18.pdf


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## melissa0414

HLD23MPC  said:


> I do the billing for an Urgent Care in Rhode Island and mostly the BCBS billing. Instead of modifiers 59 use XU & XS and always make sure those are on any 9 codes and mod 25 is on E&M.




Well...come to find out, it's the new enhancement to their code-auditing software and this is a nationwide problem.  Our specialty organizations along with the Department of Insurance and the Advocacy Council are trying to get BCBS to rescind this 'update.'  

I have only gotten one answer back on all of my dozens of appeals - and it simply says that they follow CMS guidelines, so you may definitely have something there with the XU and XS modifiers.  I'm going to try sending them back as corrected claims with the appropriate 'X' modifier and see what happens then.  

This is just crazy.  Just when things are going smooth, yet another insurance company throws a hurdle at us - for no apparent reason.  

Thank you for your input!!!


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## ellzeycoding

Anthem has rescinded the proposed E/M reductions with  modifier 25

https://wire.ama-assn.org/practice-management/win-doctors-anthem-rescinds-pay-cut-same-day-services


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## janet@drlb.net

I occasionally get denials from various BCBS plans for the E&M, even when billed with modifier 25.  Usually if I just send notes & request a review, it gets paid.  It's still a pain to have to do so!


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## melissa0414

janet@drlb.net said:


> I occasionally get denials from various BCBS plans for the E&M, even when billed with modifier 25.  Usually if I just send notes & request a review, it gets paid.  It's still a pain to have to do so!



Ya know, I've been doing that also - appealing w/ records.  But I'm not having much luck.  I just get another denial back stating 'we utilize CMS/CPT coding guidelines and industry standard coding practices.'  So this makes me wonder if all of a sudden, BCBS wants the X-modifiers.  I'm trying it out on a handful of claims and will let y'all (yep...I'm from Texas y'all) know what comes of those.


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## ellzeycoding

X modifiers aren't for separately identifiable E/M services... only procedures.

You may indeed NOT have a separately identifiable E/M service.  I did an audit the other day and the provider was wanting to bill an E/M with new and established patient visits when the patient had specific complaints that each let to one or more minor procedures. 

The E/M that leads to the decision to perform minor procedures is included in the reimbursement for the minor procedures. The E/M is only billable if it separately identfiable (e.g., usually for a separate unrelated issue) from the procedures.  This rule about minor procedures and E/M being bundled is true for new and established patients.


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## melissa0414

ellzeycoding said:


> X modifiers aren't for separately identifiable E/M services... only procedures.
> 
> You may indeed NOT have a separately identifiable E/M service.  I did an audit the other day and the provider was wanting to bill an E/M with new and established patient visits when the patient had specific complaints that each let to one or more minor procedures.
> 
> The E/M that leads to the decision to perform minor procedures is included in the reimbursement for the minor procedures. The E/M is only billable if it separately identfiable (e.g., usually for a separate unrelated issue) from the procedures.  This rule about minor procedures and E/M being bundled is true for new and established patients.



So since you do derm, if a new patient were to come in c/o contact dermatitis.  And the physician goes over the patient's history, does the ROS, physical exam, etc...and then decides to put on a patch test the same day.  The physician could not bill for an office visit (in addition to the patch testing)?  That doesn't sound correct.  

Our issue pertains mostly to allergy injections.  If a patient comes in for their monthly allergy injection and they're also there for their yearly follow-up with the physician, BCBS is paying for the allergy injection and not the office visit.  It makes no sense.  So...I am trying the XU modifier with the allergy injection - in addition to the 25-modifier on the visit to see if that helps.  It's only certain BCBS plans doing this - Texas, Oklahoma, Illinois, New Mexico, and a handful of other states.  This was never an issue before, but now has become quite a thorn in my side.  I'm watching the ones that I sent out with the XU modifier to see if that may truly be the issue.  

Melissa Sandlin, CPC


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## ellzeycoding

melissa0414 said:


> So since you do derm, if a new patient were to come in c/o contact dermatitis.  And the physician goes over the patient's history, does the ROS, physical exam, etc...and then decides to put on a patch test the same day.  The physician could not bill for an office visit (in addition to the patch testing)?  That doesn't sound correct.
> 
> Our issue pertains mostly to allergy injections.  If a patient comes in for their monthly allergy injection and they're also there for their yearly follow-up with the physician, BCBS is paying for the allergy injection and not the office visit.  It makes no sense.  So...I am trying the XU modifier with the allergy injection - in addition to the 25-modifier on the visit to see if that helps.  It's only certain BCBS plans doing this - Texas, Oklahoma, Illinois, New Mexico, and a handful of other states.  This was never an issue before, but now has become quite a thorn in my side.  I'm watching the ones that I sent out with the XU modifier to see if that may truly be the issue.
> 
> Melissa Sandlin, CPC




Ahh.... but you overlooked one IMPORTANT point.   CPT 95044 (Patch testing) isn't a minor procedure. Minor procedures have 0 or 10 postop days. For CPT 95044, the global concept doesn't apply.

In this case, if the E/M leads to the decision to do patch testing on the same DOS, you CAN bill the provider's E/M that lead to the decision to perform it separately.

Now, there are 95044 bundles in the CCI, because the if the patient is just coming in for application of the patches (decision was done previously), you can't bill for an E/M.  Similar for a patient coming into the office for a routine scheduled injection (96372).

You can bill for the reading of the tests at 24, 72, 96 hours (usually a 99211 if nurse does it or 99212 if provider reads the tests).  And you can bill an E/M for the final meeting with the patient to go over the results and discuss the plan of care moving forward.

In my previous post, I was talking about minor procedures (codes with 0 and 10 postop days) and the E/M that leads to the decision to perform it being _included_.   This came about in 2013 with the National Correct Coding Initiative.  Here is the verbiage that applies to minor procedures with both new and established patient visits.

IN the NCCI Policy Manual, Chapter 3, page 8, , you will find the following instruction/rule change. 
_
"If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. *E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure.* The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.

The E&M service and minor surgical procedure do not require different diagnoses. *If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.* The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers have separate edits. Neither the NCCI nor Carriers have all possible edits based on these principles."_

What this is saying is that the Evaluation and Management required to address the patient's specific chief complaint(s) is included in the reimbursement for the billable minor procedure. This would include determining the chief complaint(s), taking or updating history, review of systems, examining the patient, past family/social history, diagnosing the problem, making the decision on how to treat the problem, informing the patient, obtaining consent, and providing postop instructions. In summary, none of the aforementioned tasks/processes can be billed for separately if they are related to a billable minor procedure.

Most of the carriers are following this rule!


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## melissa0414

ellzeycoding said:


> Ahh.... but you overlooked one IMPORTANT point.   CPT 95044 (Patch testing) isn't a minor procedure. Minor procedures have 0 or 10 postop days. For CPT 95044, the global concept doesn't apply.
> 
> In this case, if the E/M leads to the decision to do patch testing on the same DOS, you CAN bill the provider's E/M that lead to the decision to perform it separately.
> 
> Now, there are 95044 bundles in the CCI, because the if the patient is just coming in for application of the patches (decision was done previously), you can't bill for an E/M.  Similar for a patient coming into the office for a routine scheduled injection (96372).
> 
> You can bill for the reading of the tests at 24, 72, 96 hours (usually a 99211 if nurse does it or 99212 if provider reads the tests).  And you can bill an E/M for the final meeting with the patient to go over the results and discuss the plan of care moving forward.
> 
> In my previous post, I was talking about minor procedures (codes with 0 and 10 postop days) and the E/M that leads to the decision to perform it being _included_.   This came about in 2013 with the National Correct Coding Initiative.  Here is the verbiage that applies to minor procedures with both new and established patient visits.
> 
> IN the NCCI Policy Manual, Chapter 3, page 8, , you will find the following instruction/rule change.
> _
> "If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. *E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure.* The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.
> 
> The E&M service and minor surgical procedure do not require different diagnoses. *If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.* The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers have separate edits. Neither the NCCI nor Carriers have all possible edits based on these principles."_
> 
> What this is saying is that the Evaluation and Management required to address the patient's specific chief complaint(s) is included in the reimbursement for the billable minor procedure. This would include determining the chief complaint(s), taking or updating history, review of systems, examining the patient, past family/social history, diagnosing the problem, making the decision on how to treat the problem, informing the patient, obtaining consent, and providing postop instructions. In summary, none of the aforementioned tasks/processes can be billed for separately if they are related to a billable minor procedure.
> 
> Most of the carriers are following this rule!



So..you're actually talking about minor 'surgical' procedures, not just procedures in general.  Got it.  So none of this will apply to the allergy specialty that is most of my business.  BCBS is denying visits when billed with allergy shots, allergy testing, PFT's, etc...  nothing 'surgical' in their offices...not yet anyway.

Melissa Sandlin, CPC


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## ellzeycoding

melissa0414 said:


> So..you're actually talking about minor 'surgical' procedures, not just procedures in general.  Got it.  So none of this will apply to the allergy specialty that is most of my business.  BCBS is denying visits when billed with allergy shots, allergy testing, PFT's, etc...  nothing 'surgical' in their offices...not yet anyway.
> 
> Melissa Sandlin, CPC



Probably not, but still pay attention to Postop days.  If a code has 0 or 10 postop days it's considered a minor procedure. Doesn't have to be "surgery" necessarily...


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## ellzeycoding

I looked up the NCCI Policy Manual for Allergy Testing and Immunotherapy... there are some rules outside of the minor procedures policy I mentioned.

Here is the entire excerpt... there is a specific rule regarding E/M visits needing to be separately identifiable.  In other words, no E/M when the patient is in for a scheduled injection or test.  But if there is a separate E/M that leads to the decision to do the testing, or for an unrelated matter, you can charge for it.

_
"K. Allergy Testing and Immunotherapy

The CPT Manual divides allergy and clinical immunology into testing and immunotherapy. Immunotherapy includes codes for the preparation of antigen (allergen) and separate codes for allergen administration.

1. If percutaneous or intracutaneous (intradermal) single test (CPT codes 95004 or 95024) and “sequential and incremental” tests (CPT codes 95017, 95018, or 95027) are performed on the same date of service, both the “sequential and incremental” test and single test codes may be reported if the tests are for different allergens or different dilutions of the same allergen. The unit of service to report is the number of separate tests. A single test and a “sequential and incremental” test for the same dilution of an allergen shall not be reported separately on the same date of service. For example, if the single test for an antigen is positive and the physician proceeds to “sequential and incremental” tests with three additional different dilutions of the same antigen, the physician may report one unit of service for the single test code and three units of service for the “sequential and incremental” test code.

2. Photo patch tests (CPT code 95052) consist of applying a patch(s) containing allergenic substance(s) to the skin and exposing the skin to light. Physicians shall not unbundle this service by reporting both CPT code 95044 (patch or application tests) plus CPT code 95056 (photo tests) rather than CPT code 95052.

*3. Evaluation and management (E&M) codes reported with allergy testing or allergy immunotherapy are appropriate only if a significant, separately identifiable service is performed. Obtaining informed consent is included in the immunotherapy service and shall not be reported with an E&M code. If E&M services are reported, modifier 25 should be utilized.*

4. In general allergy testing is not performed on the same day as allergy immunotherapy in standard medical practice. Allergy testing is performed prior to immunotherapy to determine the offending allergens. CPT codes for allergy testing and immunotherapy are generally not reported on the same date of service unless the physician provides allergy immunotherapy and testing for additional allergens on the same day. Physicians shall not report allergy testing CPT codes for allergen potency (safety) testing prior to administration of immunotherapy. Confirmation of the appropriate potency of an allergen vial for immunotherapy is an inherent component of immunotherapy. Additionally, allergy testing is an integral component of rapid desensitization kits (CPT code 95180) and is not separately reportable."_


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## autumnw09

HLD23MPC  said:


> I do the billing for an Urgent Care in Rhode Island and mostly the BCBS billing. Instead of modifiers 59 use XU & XS and always make sure those are on any 9 codes and mod 25 is on E&M.



Use both the XU & XS instead of 59?


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## lkaycreasy

melissa0414 said:


> Ya know, I've been doing that also - appealing w/ records.  But I'm not having much luck.  I just get another denial back stating 'we utilize CMS/CPT coding guidelines and industry standard coding practices.'  So this makes me wonder if all of a sudden, BCBS wants the X-modifiers.  I'm trying it out on a handful of claims and will let y'all (yep...I'm from Texas y'all) know what comes of those.



Have you tried submitting LCD’s from CMS/CPT as documentation supporting the correct billing? best of luck


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## melissa0414

autumnw09 said:


> Use both the XU & XS instead of 59?



I've tried both, but those aren't working either.  Out of the dozens - actually hundreds by now - that I have appealed with records, TWO have been paid.  And those two were faxed back-to-back on the same day to BCBS.  So...I guess I just got lucky with a smart BCBS person.  

I'll have to see if I can find the CMS documentation...maybe that will work.  It's getting pretty tedious though as I have a hundred more newer claims that have been denied to deal with also.  Just another burden for billers and coders.  

Happy Friday!!


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## Bairdg1995

*Physical Therapy Biller*

We've been getting denials from BCBS of Texas for the 59 modifier. I am currently with a large physical therapy practice, we are billing CPT codes 97140 along with 97530.  The 59 has been applied to 97530, but BCBS of Texas has denied, reasoning CARC CO-4 (Invalid modifier combination). They requested to appeal the claims which is a tremendous amount of work, because these treatments are a part of physical therapy.  We attempted to submit corrected claims and add XE modifier to 97530.  The weird thing about it some of our claims paid and some denied for the very same reason originally invalid HCPCS modifier combination.   Help can anyone offer any advice or suggestions. 
Just to add they are paying for CPT code 97140


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## crogers@accelhc.org

*BCBS Denial:  Invalid Combination of HCPCS Modifiers*

We have been getting paid for both E/M and the administration (90471) up until now.  We bill a 25 on the E/M and a 59 on the 90471.  BCBS is denying the E/M stating invalid combination of HCPCS Modifiers?   
Our dx code for the 90471 is not billed on the E/M.  Is anyone else having this issue?  

I appreciate any help on this issue. 

Thanks


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## erjones147

You do not need a -59 on the immunization administration


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## crogers@accelhc.org

BCBS is paying on the 90471-59 but not the E/M?   What has changed?  Why are they all of a sudden denying our E/M visits?


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## marthaarr@qwestoffice.net

*Rheum coder*

We are also having this (new) issue with BCBS across the board.  We are billing an E/M code, with a 25 modifier, on IV infusion patients 3 X a year for monitoring of the IV infusions.  We have never had an issue with getting paid for these. It is my understanding that we are allowed to bill E/M codes (with 25 mod) on these (IV infusion) patients under CMS guidelines. I have read several articles, but I haven't been able to find anything to prove, or disprove my case either way!  
Now we are getting denials on 96365 with an XU modifier when administering Benadryl during an IV infusion.... HELP!! Does anyone have any info about these 2 issues and how we can actually get reimbursed for the services we are providing?

Martha


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## GCLindsay

melissa0414 said:


> I do billing for five different practices across Texas and am having an issue with BCBS.  They are denying most E/M codes when we use the 25-modifier (to distinguish from other services rendered the same day).  I've gotten dozens of these so far.  I have read some info online from different practices that BCBS is going to reduce reimbursement on E/M's when billed with the 25-modifier to 50% of the allowed amount.  But I haven't seen anything in black and white from BCBS itself.  Does anyone have any hard information on this change?  The dozens of appeals are KILLING me.  Maybe I shouldn't have taken on five practices.




I see this a lot when we code from 20600-20611 range and we found out that some payers are enforcing a guideline on the CPT where a 59 should be applied to the 20600-20611 code in order to unlock payment for the E/M. It doesn't make much sense and we're still waiting to see if it worked for us.


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## ALozano25

Easier way to appeal these are through availity. Through refund management ERM. Talk to your availity rep and they can walk you through the process. There is a few forms provider might have to fill out or sign but you can upload pt records here vs appealing each and every one of them! Just a few clicks away so much easier for now until issue is resolved!


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## millbj

melissa0414 said:


> I do billing for five different practices across Texas and am having an issue with BCBS.  They are denying most E/M codes when we use the 25-modifier (to distinguish from other services rendered the same day).  I've gotten dozens of these so far.  I have read some info online from different practices that BCBS is going to reduce reimbursement on E/M's when billed with the 25-modifier to 50% of the allowed amount.  But I haven't seen anything in black and white from BCBS itself.  Does anyone have any hard information on this change?  The dozens of appeals are KILLING me.  Maybe I shouldn't have taken on five practices.




Melissa-

Did  you ever get this figured out.  I am having the exact same issue with BCBSTX.


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