Wiki E&M's with procedures

[dewittd@wvumedicine.org]

Good Morning,
I am getting a ton of denials on procedures, (scopes) and E&M. I need some help. What are the guidelines you use to be able to bill both. We are using the 25 modifier but they are still getting denied. The insurance company will only pay for one or the other. They state that the services are bundled.
Help Please.
thanks,
Debbie

 

[mitchellde]

if the procedure were scheduled from a previous encounter you cannot bill another E&M on the day of the procedure. If it were not prior scheduled but the E&M is not considered significant from the evaluation needed for the procedure then you cannot bill the E&M. It is all dependent on the documentation. Many payers have discovered on post audit that the documentation is insufficient to support the use of the 25 modifier so they have a policy to deny all E&Ms with a procedure even with a 25 modifier until you can successfully appeal to show you have the necessary documentation to back it up.