# Medicare denying E/M



## tholcomb (Jun 19, 2013)

Good afternoon fellow Coders,

Patient came in for follow up exam 99215 and cpt 69210 removal impacted cerumen Medicare paid 69210 but denying office visit as PAYMENT IS INCLUDED IN THE ALLOWANCE FOR ANOTHER SERVICE/PROCEDURE could I appeal this or would adding modifier 25 to the E/M be sufficient?

Thank you,
TH


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## la_0922 (Jun 19, 2013)

Usually the modifier 25 is sufficient, but make sure the office note not only supports the level 5, but the 25 modifier as well. 

Thanks, 
Louise CPC


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## swilliams2 (Jun 20, 2013)

*69210*

Also make sure your documentation supports the 69210. Medicare has certain criteria that must be met for billing this code-certain method to performing the procedure. I would also be sure a 99215 is supported, -follow-up?? A 99215 should have high MDM and is that the case with a follow up?


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## mitchellde (Jun 20, 2013)

honestly you bill a level with a 69210 without a 25 modifier the payer will pay which ever is the least.  Sometimes even with the 25 modifier the visit will deny.  You need to support every thing you bill with modifiers and with the dx codes.  When you bill a 69210, it must be a procedure performed by the physician and cannot be an irrigation.  If you are going to use a 99215 your dx code needs to support this and of course the documentation needs to support the patient's medical necessity required that level of work.


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## tholcomb (Jun 20, 2013)

Thank you ladies for you responses I will make sure the documentation supports the level 5 visit.


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