Ob-Gyn Coding Alert

Question:My ob-gyn performed the work described by 76817-26 and99243. However, we received a denial for 99243. The payer stated the consult was inclusive to the 76817 code. What did we do wrong?

Texas Subscriber

Answer: You should send in a corrected claim with 99243-25 (Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity ...; Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 76817-26 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal; Professional component). The reason your payer did not pay the consultation is because you did not add modifier 25, to show this was a "significant, separate E/M service." Even though this is not a CPT® requirement, more payers are now insisting on seeing modifier 25 before they will pay for the E/M service on the same date as an ultrasound or other diagnostic procedure.