Wiki IUD Removal Modifier

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dan528i

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I had a pt present in the office for a preventative visit, with complaints of pelvic pain. I billed 99386 (dx V72.31), 99212-25 (dx 627.2). At the end of her exam, she decided to remove her IUD, and the doctor did it on the same DOS. Therefore, I also billed 58301 (dx V25.42). The original claim got paid, but 58301 was denied.

I sent an appeal, with modifier 25 attached to the 58301 code, but that is now being denied stating "modifier being inappropriate for the procedure code."

Can anyone please let me know what modifier to use? I'm leaning towards 51, but am not sure.

Thanks!
 
Modifier -25 can only be appended to E&M codes. Try -25 attached to 99386. Be prepared to provide documentation, though.
 
Modifier -25 can't be applied to a preventative visit, so I can't add it to the 99386 code. It seems that there's a different modifier I can use on the 58301 code itself, I'm just not sure which one that is.
 
Could you tell me what documentation you base that on? I don't bill for preventive services so I am not as familiar with that set of codes as you are I'm sure but I have been searching for something that says you can or can't use -25 with preventive services and can't find anything either way.

I have found several policies posted on line for specific payers that advise billers to append -25 to the preventive codes when billing with developmental testing but we all know that every payer has their own way of coding. I also found a couple that said the preventive codes are special and don't need a modifier, that they are inherantly separate from the other billed services but they were in message boards like this one and did not give a source for that information.

I checked with a couple other coders locally and they were not aware of any rule against using -25 with preventive services either but then again, they don't bill preventive services. If anyone has this documented anywhere, i would love to see it.
 
You can actually use mod -25 on any E/M including preventive codes. In your case I suggest:
99396-25
99212-25
58301
I plugged these into Anthem clear claim connection and all are allowed (supposedly). According to CCI edits this is acceptable also.
Who is your payor?
 
I agree, you can use the mod -25 on preventative codes, this is ONLY allowed though when you are billing a preventative code and a "procedure" of some sort. In this case it would be the 58301 that is the "procedure", therefore they should pay for it.
 
did I miss it? what was the reason by which the insurance denied 58301? I didn't see it anywhere. But this is what I found in: " The OB/GYN comprehensive guide to coding and reimbursement " coding companion book states: "...Because this procedure is usually not done out of medical necessity, the patient may be responsible for the charges. Verify with the insurance carrier for coverage". I hope this helps you!
P.S.: the book is from 2009 I haven't got the 2010 yet!
 
You're billing an est pat 99212 with an initial comprehensive prev 'NEW PT'99386 CODE. That is the issue. If you meant 99396 than I agree with the other posts 58301 should be paid. I would call them and see why it is denied.
 
Hey Guys THANK YOU all for your inputs I really appreciate them.
The carrier is AMERICHOICE ny UHC of NY and all codes are covered for by this plan (when billed separately :0). But i will try to add modified 25 to the preventative and will keep you posted on the results.

AGAIN THANKS A LOT EVERYONE !!!
 
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