Wiki 99214 and 94640 unbundled documentation

[tpgrice]

It seems absolutely silly that the bundled payment only covers the minimally priced 94640 instead of including the 94640 in the 99214. Even so, what sort of documentation should be present to support the unbundling of the exam? Are they saying that the office visit has to be for more than the reason the patient needed the treatment? I do not want to get flagged for over using the 25 modifier on this but everything i have read so far says to do it. Is there an expert who can tell me exactly how to bill for the exam and the treatment without raising flags? Or should we just cut our losses and only file the exam?
Please help!! I know this has been covered in the forum previously but i am only pulling up old stuff and want to make sure i have the most current information on this. Thanks in advance!

 

[tpgrice]

No reply on this yet.

I don't see any replies to this issue. Is anyone available to help?

 

[Chelle-Lynn]

When billing for 99214 and 94640 the same rules would apply for the use of the modifier 25 as normal. We see this often in the following scenario:

• Patient comes in for abdominal pain and earache
• While here the provider notices wheezing during the respiratory exam
• The provider then orders the breathing treatment which is administered
• The provider then goes on to address the abdominal pain and earache.

For 94640 to be considered significant and separate in this case we would look for the following documentation to support the breathing treatment in addition to the standard E&M:

• Symptoms or condition that led to the need for a breathing treatment (wheezing, short of breath, etc)
• Documentation that the treatment was administered including dosage of any medications used.
• The patients condition at the conclusion of the treatment (wheezing resolved, SOB reduced, no change, etc)

As long as we can see the reason for the treatment, the verification of the treatment being administered, and the affects of the treatment, we would code the E&M with a modifier 25 and the 94640 as an additional services in the scenario above.

If the patient came in for the purpose of shortness of breath or wheezing, then in most cases we would not consider it separate. As always it depends on the documentation. Hope this helps.