Reminder: Refile Denied Claims for Same-Day E/M, Diagnostic Tests

Allergy testing is usually accompanied by an E/M service. For example, the physician may take a history and perform an examination to assess the patient before the tests are administered. The doctor is also likely to discuss test results and/or re-examine the patient if the test yields a certain result. Because these are diagnostic tests, they are payable separately when performed at the same time as an E/M service.

In the national Physician Fee Schedule Relative Value File, allergy tests, like virtually all diagnostic tests, have "XXX" global days. Until October 2000, the global surgery package, which bundles E/M services performed during the global period of a procedure, did not apply to diagnostic tests, including all allergy tests.
 
However, in October 2000, Version 6.3 of the CCI added more than 50,000 edits involving E/M services and diagnostic tests performed on the same day. Providers were instructed to append modifier -25 to any E/M service performed on the same day as any diagnostic tests. This had an immediate and significant impact on practices. In some cases, claims were being denied even when modifier -25 was correctly appended to the appropriate E/M service.
 
Due to the ensuing uproar from physicians nationwide, the edits were "suspended" three months later (January 2001), pending review by the Centers for Medicare & Medicaid Services (CMS, formerly HCFA). According to CMS, any claims that were denied following the introduction of version 6.3 should be refiled. However, rejected claims must be refiled within a year of the submission of the original claim. Because the edits became effective Oct. 1, 2000, the 1-year deadline will soon arrive, so it is imperative to refile claims made between Oct. 1, 2000, and Jan. 1, 2001, as soon as possible.
 
Note: Some Medicare carriers have not yet changed their software, which means they may require modifier -25 to be attached to E/M services performed with  diagnostic tests even though the edits were suspended. Allergists should ask their Part B carriers if they still require modifier -25 on such claims.

- Published on 2001-09-01