Wiki E&M rejecting with injection not planned

Create Wiki
T

tmeddaugh@yahoo.com

Guest
Messages
5
Best answers
0
We are a Hand Surgery group and have suddenly seen numerous denials for our billed office visit when a patient comes in, is examined and our Doc decides to give the patient an injection (example a steroid injection to relieve pain). This injection is not preplanned. We have always used a 25 modifier on the injection code, but are now having these all reject. Any suggestions, or are we incorrect in feeling that the doctor should get paid for his decision making skills and the exam itself? Thanks for any help.
 
Is it any one insurance you have having problems with? I know we have trouble with Care Improvement Plus denying the injection itself a lot.
 
It suddenly has been a wide range of insurance carriers. I was just questioning my correct coding practices, but feel the Doctor is entitled to be reimbursed for his exam and decision making process as long as the injection was not pre-planned. We've appealed with notes and that reasoning, however, continue to get responses stating they "maintain their original decision". It really makes me wonder whether there is really someone reviewing the appeals. Thanks for your response.
 
Did you actually put modifier 25 on the injection code? If so that could be the reason for the denial right there, modifier 25 should only ever be used on E/M codes, NEVER on anything else. I would check and make sure the modifier is on the office visit and if not, switch it and resubmit.
 
Per CCI edits:
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an
E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. (Medicare): Revision Date 1/1/2013 I-18

So, In my mind, Significant and separately identifiable does not mean the provider's decision to perform procedure. That's bundled into the minor procedure. Most payers are now following this CCI edit and even with a -25 will not pay.
 
You must log in or register to reply here.
Top