Wiki CPT 99386 and 99204

[Meganbohnert]

Hello,

Needing some help with a question. I received a denial from Ambetter. I coded a New Pt preventative care and a NP E&M with a modifier 25. They are saying that NP qualifications were not met on the 99204. Should i be using a 99214-25 instead of the 99204? Any help is appreciated!! Thanks!

 

[Elizabeth.Herzog]

Hello,

Needing some help with a question. I received a denial from Ambetter. I coded a New Pt preventative care and a NP E&M with a modifier 25. They are saying that NP qualifications were not met on the 99204. Should i be using a 99214-25 instead of the 99204? Any help is appreciated!! Thanks!

I know this subject has been brought up a lot. From a CPT coding perspective, it is appropriate to bill both new patient codes, but from a reimbursement perspective, the second new patient visit is often denied as most payers will only allow one new patient visit. It is frustrating as we want to follow coding rules, but payers also have their own reimbursement rules. I really feel like this just comes down to the payer guidelines.