Wiki Help with coding I&D in office procedure

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fferali

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An 11 yr old was seen in the office on these dates:

03-22-2010 DX: 704.8 ( folliculitis ) 99213 Claim was paid.

03-23-2010 patient not better DX: 682.3 (Cellulitis and Abscess upper arm& forearm) 99213 Claim was denied as "Pre-Post op care payment is included in the allowance for the surgery/procedure"

03-24-2010 patient not better DX: 682.3 (Cellulitis and Abscess upper arm& forearm) 99213 25 and 10060 I&D Claim was denied as "Pre-Post op care payment is included in the allowance for the surgery/procedure"

03-25-2010 patient not better DX: 682.3 (Cellulitis and Abscess upper arm& forearm) 99213 a Decision was made to send patient to the ER and patient was admitted. Our doctor did not see patient in the Hospital. Claim was paid.

03-29-2010 patient much better F/U from hospital DX: 682.3 (Cellulitis and Abscess upper arm& forearm) 99213 Claim was denied as "Pre-Post op care payment is included in the allowance for the surgery/procedure":confused:
 
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RE: the 3/23/10 E/M denial: Office visits the day before can bundled into a procedure. You can try to resubmit adding a 25 modifier.

RE: 3/24/10 denial: With each procedure performed there is a component of E/M included. I go through this with my providers all the time. You can try resubmitting or appealing and adding the 25 modifier and sending notes, however, the key to the 25 modifier is that the E/M must be significant and separately identifiable from the procedure.

RE: 3/29/10 denial: Procedure 10060 carries a 10 day global period. Page 29 of May 2010 has an excellent article to define what is included in the global surgery package based on CPT vs. CMS guidelines. You will need to determine whether the documentation on this date of service supports the use of a 24 modifier (unrelated E/M service by the same physician during a postoperativer period) or whether this visit should be considered P/O to the procedure done on 3/24/10.

Hope this is helpful.

Jessica, CPCD :)
 
I'm confused on what you were paid for and what you were not paid for?

The 3/22 visit should have been paid.

The 3/23 visit should have been paid - the procedure 10060 has a 10 day global and should not include the day prior to the service. You would not need the 25 modifier because that is only used if the procedure is done on the same DOS.

The 99213 on 3/24 could be denied as part of the procedure if there was not a separately identifiable service and considering the doctor saw the patient the day before for the same dx I can see the denial for the 99213, however you say the claim denied - did that include the 10060? I would hope they paid for this - this is the procedure and should have been paid.

The 99213 on 03/25 should NOT have paid - this would be part of the global for 10060 - which has a 10 day global.

The 99213 on 03/29 denied correctly - this is part of the global period.

Have you contacted the insurance to see why they processed your claims this way? I would contact them to see what is going on! :confused:

Jodi Dibble, CPC
 
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