Wiki Denials for 96372 & same day E/M MULTIPLE CONDITIONS.

[cnjacobs15]

I am having a huge issue with Highmark only paying on the 96372 and B12 injections and denying the E/M even with modifier 25 when there are other conditions being addressed.
An example i have a patient who comes in to see the provider for multiple conditions but also due for their B12 injection
Conditions addressed and documented accurately are J45.40 - Moderate persistent asthma, uncomplicated J30.2 - Other seasonal allergic rhinitis And E53.8 - Deficiency of other specified B group vitamins
It is billed as
992xx- 25 ICD10- J45.40, J30.2, E53.8
96372- E53.8
J3420- E53.8

The provider evaluates all conditions, orders medications for those conditions and also orders the B12 injection which the LPN administers the injection under the supervision of the provider.. From my understanding it is correct to bill the EM and addressing the other conditions it qualifies as separate. But even with the diagnosis ordering Highmark continues to deny the EM.. I have had times where i provide the documentation as well and they uphold their decision.

Am i understanding this wrong and this does not qualify to use modifier 25? I truly feel that it does. but if anyone has any advice or information please let me know!

 

[slc112071]

I am having the reason issue, but with Healthchoice out of Oklahoma. I have tried appealing with notes, everything possible and they still will not pay the E&M codes. I have even pointed out that in my case, they were not planned injections. I don't know what else to do.

 

[narredondo1103@gmail.com]

You are understanding the use of -25 correctly. Sometimes reaching out to provider relations help get issues resolved. All the commercial payers are cracking down on E/M with modifer -25. I am sure it goes through their edit and automatically denies. Has anyone called and spoken to someone to have it escalated as well? Sometimes that works to verbally fight it out when supporting documents has been submitted. Good luck

 

[Plaidkat]

I am having a huge issue with Highmark only paying on the 96372 and B12 injections and denying the E/M even with modifier 25 when there are other conditions being addressed.
An example i have a patient who comes in to see the provider for multiple conditions but also due for their B12 injection
Conditions addressed and documented accurately are J45.40 - Moderate persistent asthma, uncomplicated J30.2 - Other seasonal allergic rhinitis And E53.8 - Deficiency of other specified B group vitamins
It is billed as
992xx- 25 ICD10- J45.40, J30.2, E53.8
96372- E53.8
J3420- E53.8

The provider evaluates all conditions, orders medications for those conditions and also orders the B12 injection which the LPN administers the injection under the supervision of the provider.. From my understanding it is correct to bill the EM and addressing the other conditions it qualifies as separate. But even with the diagnosis ordering Highmark continues to deny the EM.. I have had times where i provide the documentation as well and they uphold their decision.

Am i understanding this wrong and this does not qualify to use modifier 25? I truly feel that it does. but if anyone has any advice or information please let me know!

I am having the same issue with Aetna Medicare.