mbellar
Networker
Having issues with denials from payer stating the E&M is not covered due to a previous E&M within the past 90 days was filed with the same diagnosis code.
There is no P/O period on these claims and the dx code is different from minor procedure and is separately identifiable.
Is anyone running into these issues? Appeals are being upheld for E&M
Policy
Script
The billed E&M service was denied because it was performed the same day as a procedure with a 0-day,10-day,90day P/O period based on CMS policy.
Rationale
According to our policy, which is based on CMS policy, when an E&M service is billed with mod-25 on same day as a procedure the E&M is payable only if its significant and separately identifiable. Therefore if the patient has had
a previous face-to-face visit for the same or similar dx as the E&M service with mod-25 and the procedure, then the E&M service billed with mod-25 will be denied.
There is no P/O period on these claims and the dx code is different from minor procedure and is separately identifiable.
Is anyone running into these issues? Appeals are being upheld for E&M
Policy
Script
The billed E&M service was denied because it was performed the same day as a procedure with a 0-day,10-day,90day P/O period based on CMS policy.
Rationale
According to our policy, which is based on CMS policy, when an E&M service is billed with mod-25 on same day as a procedure the E&M is payable only if its significant and separately identifiable. Therefore if the patient has had
a previous face-to-face visit for the same or similar dx as the E&M service with mod-25 and the procedure, then the E&M service billed with mod-25 will be denied.