Wiki billing ED visit and admission

[apollo06]

Hello, we are seeing denials of our ED visits deny inclusive to the admissions. Two different specialties obviously. We do have the same taxonomy but big multispecialty childrens group. Payer is requesting a mod on one of the E/Ms. I am not a billing person really only coding background so i am trying to understand why this would happen and what modifier would be appropriate? 27? Thank you

 

[thomas7331]

Modifier 27 is for use on facility claims only, so that is not likely going to work.

I think that if the two providers are of different specialties, then this is a problem with the payer, not with your coding. Someone in your billing department should be working with those payers to find out why they are not correctly recognizing the specialties of the individual providers. It could be a problem with how the claim form is being populated, but more than likely it is an issue with the payer's claims system or with how the providers were set up when they were credentialed or enrolled with the payer. I would not recommend changing your coding process or otherwise trying to find a workaround to avoid denials until you've identified the root cause of why these claims are being denied. If all else fails, I would appeal the denials with documentation showing that the providers are of different specialties.

 

[csperoni]

You state different specialties, but same taxonomy code. The taxonomy code is how the insurance determines your specialty.
If the physicians are credentialed with insurance as the same specialty, that could be the reason you are receiving the denials.

 

[apollo06]

Thank you for your replys.