Wiki Denial of Full Skin Exam Office visits

[LBernat7]

Hi
We are getting denials from IBX (we are in PA) when the Dr does a full skin exam but also performs say a biopsy or Destructions same day the full skin exam (office visit) is being denied as inclusive to the procedures now they are all different diagnosis and modified as such this is the first we are seeing this over last couple of weeks and this has been a riactice for 25 yrs

99213 (DX: Z12.83 (full), Z85.820 (Hx MM) or Z87.2 (HX of Diseases of Skin ) etc modifier 25
11102 (DX: D49.2)

any help is appreciated. We don't know if we should write off the OV as it should not have been charged or fight with ins

 

[thomas7331]

I'd start by reviewing your payer's reimbursement policy for E&M services billed on the same day as a procedure. But if they don't have anything specific to explain this, and the denial is saying it is inclusive, then if your documentation supports the modifier 25 and shows that E&M services above and beyond what is a normal part of the procedure, then you should appeal with documentation showing that the E&M code should be paid. At least if you appeal, then it forces them to send you some kind of explanation as to their rationale that will hopefully give you some insight into what the payer requires.

 

[LBernat7]

there is nothing specific in their reimbursement policy for E&M in the past up until about 3 weeks ago it paid just fine we reviewed their website or policy changes and nothing that's I guess what I was asking. If the provider if doing a full scan of the body and pt has a history but only one BX is performed they thing they deserve the E&M as well as the BX seems as though now insurance is saying otherwise