# What Is Wrong?



## willlen

I am billing Medicare for Doctor of Osteopathy (DO) using 2 codes: E/M code99213 with modifier 25 and code 98926 - osteopathic manipulation. For many years we got payment for both codes. Suddenly, week ago I got payment only for code 98926 and zero for code 99213 wich was bundled with code 98926. What happened? And what can I do?
Thanks.


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## dmaec

Appeal it if you have supporting documentation.  If you can show that the E/M is "significant separate identifiable".  You should be able bill it with the .25 modifier along with the 98926.


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## member7

I agree.  You should appeal it.  Maybe the carrier put some edits in place that kicked out your claims in error.


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## thompsonsyl

Hi,

I can't seem to log on to the CCI Edits webpage but have you looked your codes up there?

If your second code is considered a component of the e/m code, it will require that you append a -59 modifier.

Hope this helps!


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## dpage77

Modifier -25 indicates that a separately identifiable E/M
service was performed on the same day as another independent procedure
or service by the same physician. When a code from the special services,
procedures and reports section is reported with an E/M service, Modifier
-25 should not be appended to the E/M service, as the codes from the
99000-99091 series do not describe separately identifiable services, but
rather adjunctive services or circumstances that further describe the
basic service rendered."


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## willlen

*Thanks, but question remains*

Thanks for all the feedback.
Thank you, Sylvia for your reply. I know in the CCI Edits code (98926) is a component of the E/M code 99213. But does it require exactly modifier -59 or some modifier, in particular mod. -25? Now the issue of appending 59 vs 25 has come up. I think modifier -25 is more appropriate to use in this situation than a mod -59? I use mod. -25 with the code 99213 for many years and did not have any problems until now. OK, I will resubmit a claim with mod. -59 and will see what happen.


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## Lisa Bledsoe

Just out of curiosity, did your Medicare carrier recently change?  We have had a tremendous amount of problems since our carrier changed.


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## ruhood

Look at the narrative in the CPT book above the section that contains code 98926.  It indicates that mod. 25 should be used on the E/M service.  I would point to that in my appeal.


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## thompsonsyl

Hi,

Willen....cpt narrative does state that a same dos e/m would require a (-25) modifier.  The only caveat I see is that in order to "unbundle" procedures (CCI), modifier (-59) is typically what is used on the "component code".  I'm curious to see how your claim will process.  Let us know!


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## OliviaPrice

I just wanted to comment of the use of modifier -25 vs -59.  Modifier -25 is used on E/M codes to seperate it from a procedure.  Modifier -59 is used on procedure codes to seperate it from another procedure code.  You should never append modifier -59 to an E/M code.


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## thompsonsyl

Hi,

To add to what "priceor" stated....

(-59) can also be used on "Medicine" codes....surprisingly enough....I learned that not too long ago while doing some audits.  Prior to this, I, too, was under the impression that (-59) was only for "procedures".


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## Judith Fletcher

*Billing Coordinator*

We came upon this problem and it was quite frustrating for us.  We discovered that some payors make quite a distinction on the way they pay for "physical medicine" codes and the contract for Medical Doctors may be different then for Doctors of Osteopathy.  We finally came with an alternative code that seemed to be exempt for all the road blocks and that code is 97140.  I would still make use of the modifier "25" if is in addition to another e&m visit if unrelated.


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## abyrne

willlen said:


> I am billing Medicare for Doctor of Osteopathy (DO) using 2 codes: E/M code99213 with modifier 25 and code 98926 - osteopathic manipulation. For many years we got payment for both codes. Suddenly, week ago I got payment only for code 98926 and zero for code 99213 wich was bundled with code 98926. What happened? And what can I do?
> Thanks.




Both codes are billable together (providing that documentation supports them).  Did you use the correct somatic dysfunction diagnosis for the OMT. 
I code for multiple DO's and they normally have a separate diagnosis for the office visit and the somatic dysfuntion (based on location) for the OMT.


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