Wiki Correct billing for 99354

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Britte

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When I bill 99354 (prolonged service 30-74min) it keeps getting denied by Anthem and some other commercial payers. Medicare is paying it. I use modifier 25 on the E&M code it is being billed with. Any suggestions? I would greatly appreciate the help!
 
You do not need a 25 modifier since 99354 is an add on code. First is the question of what does the denial state. Next is what diagnosis cod did you pair with it and last is can you defend your choices with appeal using the documentation.
 
Many payers require medical documentation to support the prolonged services and will deny for medical documentation. What is the denial you are receiving?
 
Anthem only cover Prolonged Visit for certain diagnoses. I dont have the link anymore. But it was part of ClaimsXten Anthem edit rules. I may have a list of dx but it doesnt have a code description. You can always request it by Fax by calling Anthem as well.

ICD-10-CM Diagnosis Codes: To reference the list of ICD-10-CM diagnosis codes, which Anthem may expect to be reported when prolonged service codes 99354-99355 are billed, please close out of this policy and refer to the link under Prolonged Services called “Prolonged Services Coding.”
 
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