I have 2 patients both have Humana, patient #1 99213 & 11900 the E/m being denied due to bundling even though mod 25 added, patient #2 99214 & 17000 E/M being denied due to bundling also I'm clueless any ideas???
2 things come to mind.
1. Humana doesn't like the primary ICD 9 code to also be the
diagnosis code for a procedure so sometimes they will reject the E/M code because of this. This is not an appropriate rejection since you are allowed to bill an office visit and a procedure under the same diagnosis but they like to reject it and make you send documentation to prove that there was justification for an office visit and that it wasn't just a procedure visit.
Ex. 99214-25 (diag. 702.0, 216.5, 216.6, V76.43) 17000 (diag. code 702.0) may be rejected whereas 99214-25 (diag. 216.5, 702.0, 216.7, V76.43) 11900 (diag 702.0) will be paid.
2. If the pt has Humana Medicare and it is the Humana MCR HMO they require a referral to be obtained from Humana by their PCP before they will pay any claims. That is a sudden change in our area where Humana took over for the MCR Advantage plans that were covered by another carrier and they switched people from a PPO plan to an HMO plan without making it clear to the patients that they would now be required to get referrals to go to a specialist. Our patients think MCR is MCR and had no idea that when you switch carriers and MCR plans it changes things. I don't know if that would apply in your area but that is the other reason I can see why they would deny a claim.
Otherwise as long as the E/M code has the modifier 25, the
diagnosis codes are billable for the procedures you are billing and they haven't just been in recently and had an office visit I don't see why Humana should be denying your claims.
Amber L. Newcomb, CPC
Biller and Coder for a dermatology practice for 4+ years.
