Oh, I forgot to mention when we bill Medicare Part B, they process the claim as 99205, 25 and 96118.
Why do you suppose Medicare separates the E&M out with Mod 25 to unbundle the two codes and the commercial carrier doesn't. Is there anything in writing? Thanks!
http://www.cms.gov/MLNProducts/downloads/How-To-Use-NCCI-Tools.pdf
I'm not certain why Medicare would allow it to process that way. The commercial carrier's edit system is based off of the NCCI edits. The link provided explains how the tables are used; the modifiers that are allowed to override NCCI edits are -25 for Column 2 E/M services, and -59 for Column 2 procedures. It's not necessary to have 2
procedures paired together in order to apply a -59 modifier to one.
Although conventional wisdom
usually dictates that if something's bundling with an office visit, the office visit gets the modifier, this isn't
always the case. The reason that 96118 bundles into the office visit (instead of vice-versa), is that Psychological and Neuropsychological testing incorporate many of the same functions as E/M services. In fact, the CPT guidelines go as far as to say that anything
less than the specified descriptions of these services (referred to as a 'mini-mental status examinations'), are to be reported using Evaluation and Management codes. It's an unusual circumstance, where the burden of proving that one service went above and beyond the other is reversed, with the E/M becoming the basic service, and the procedure having to meet specific criteria to be considered separately identifiable.
Normally, when you have a procedure and E/M on the same day, the procedure is one that requires some sort of pre-and post-service work (such as checking vitals, or monitoring the patient for a short time for signs of an adverse reaction). In order to be able to bill an E/M in addition to the procedure, you have to demonstrate that you met elements that went above and beyond that pre-and post-service procedure work (like gathering History information, performing a more detailed exam, and making a medical decision). However
here,
all of the E/M work could feasibly be considered a '
portion' of the procedure - the fact that an E/M was done isn't in dispute. Whether the provider went above and beyond
that and met the criteria for 96118, is. That's the reason that it's set up as the column 2 code on the NCCI edit table, and why the commercial carrier is requiring you to append a modifier to it, and not to the E/M. Medicare's allowance of the codes may very well be a mistake; it certainly goes against their own edit tables. I would advise that you ask them directly about it, so that if you need to submit a corrected claim to avoid a future payment recovery, you can. As far as the commercial claim goes - they have all of the proof they need to back up their denial. Your best bet is to comply, because they're not in the wrong. Hope that helps!
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