Wiki bundling services together-denial

[AmandaW]

I code for a hospitialist group. Other Drs that work in the same hospital (but not in my group) see the patient sometimes as well, i.e. a cardiologist, oncologist, surgeon, etc.
Got a denial stating multiple services on same day-but that other service is an E/M service from one of those other Dr's-not one in my group. So, one of my hospitialists is claiming an E/M service along with another Dr on the same day that is not in my group. The insurance rep mentioned to my biller about applying a modifier.
Would I apply a modifier to my Dr's E/M code b/c say the cardiologist saw him on the same day?

 

[m.edwards]

We run into that problem with our group of physicians on occasion.

Depending on the carrier, it could be one of a few problems. For one of the carriers we are out of network with, they require us to add a modifier 25 on our E/M services. Otherwise we get denials stating that another physician has already been paid for this service. (Sometimes insurance carriers want modifiers that truely do not seem applicable.)

If it is the initial visit for your hospitalist and they are the attending physician, you may want to try the AI modifier so if other specialties are billing initial visits also, all claims will get paid. Subsequent visits should not need a modifier unless it is a similar situation to what I mentioned above.

My final thought would be in regards to whether you are billing for inpatient or outpatient visits. Medicare will only allow the attending physician to bill outpatient codes (99218-99220 and 99224-99226). All other physicians must bill other outpatient visit codes (99201-99215). Some other carriers may be adopting this rule.

I hope this helps!

I hope this is helpfull.

 

[AmandaW]

Thank you! Yes, that helps!

It happens to be UHC-maybe they want the 25 on there. Their claims person actually used the term "bundled services" for the denial. Very familiar with AI modifier-use that frequently throughout the day-it's a subsequent visit so that wouldn't be the case. Seen by my hospitialist and the cardiologist same day. I guess we'll try to append that modifier 25 on there and see.

Thanks again!