Cardiology Coding Alert

Question: If I submit a claim for an office visit and then later receive documentation of a stress echo for the patient on the same DOS and submit a separate claim, 93016 for the stress test gets denied. Can I send a corrected claim with modifier 25 on the E/M?

California Subscriber

Answer: Check the payer’s rules on filing a corrected claim. In many cases, you’ll find instructions to wait to act until after the payer has processed the first claim (the one without the modifier). The reason is that the payer wants to avoid the issues that duplicate claims can cause.

Good news: “Use of a modifier” is one of the items listed as a clerical or minor error that allows for asking for reopening, rather than appealing, a claim, according to Medicare Claims Processing Manual, Chapter 34, Section 10.4.

Noridian Medicare, the Part B MAC for California, also includes modifiers in the list of corrections you can make. Some modifiers are excluded, but you may reopen the claim to add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

You should make the request to reopen the claim within one year of the initial determination. You can view Noridian’s reopening instructions at https://med.noridianmedicare.com/web/jeb/topics/appeals/reopening.