Navigate NCCI Edits and Payer Policy to Understand Denial
Question: We are receiving denials for CPT® code +99417 indicating included. We are billing a level 5 evaluation and management (E/M) with modifier 25 and +99417 without modifier, with separate procedures on the same day. We are experiencing +99417 denials as included while the E/M service (99215-25 or 99205-25) and the procedure are being paid (all codes meet time requirements and documentation). I just checked on Codify and it indicates modifier 25 is eligible on +99417; however, all other guidance is indicating you should not need modifier 25 on +99417 due to it being an add-on code for 99215/99205, which is already reported with modifier 25. Has anyone run into this? AAPC Forum Participant Answer: At this time, there is not a scenario where 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) would be appended to +99417 (Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpatient Evaluation and Management service)), per National Correct Coding Initiative (NCCI) edits. However, CPT® only indicates that modifier 25 is applicable to the E/M code set. It does not indicate that modifier 25 would be inappropriate with E/M add-on codes. To that point, having modifier 25 on the crosswalk for +99417 would not be incorrect, but the coder would need to determine if it would be applicable or not. CPT® code +99417 is a column 2 code to only a few CPT® codes, and all of the pairings are modifier indicator “0,” meaning that they cannot be unbundled. If you check payers’ medical policies for +99417, you may find that some payers state that they will not reimburse prolonged time codes and a couple that state that they require documentation to be submitted to support. Payers can create their own policies regarding reimbursement for specific CPT® codes. Best bet: Reach out to the payer to determine the reason for the denial. Claire Stevenson, COC, CIC, CPC, CPMA, CDEO, Medical Coding Quality Analyst, AAPC
