Wiki Modifier 25

[lacey2324]

Looking for help with some denials on claims with Moidifer 25.
We have seen an increase in our denials from payers when it comes to billing 99213-25 with 22512/ 22513. The E/M visit is for a medication refill and counseling for use of Opioids, they may also be scheduled for a TPI for an unrelated body part.
Another denial we have seen a lot lately is 99213-25 with 20610, this is by two different Providers in the same group. APP visit is for 99213-25 and then later in the day they are seeing the MD for 20610, and those are being denied as well.

I would appreciate any help.

 

[Howard1Derm]

We are a dermatology practice and have noticed an increase in denials for the office visit when using mod 25. From what I have found online, some insurance companies are automatically sending claims with an EMN charged, modifier 25 used, and billed with a minor procedure for review. If upon further review (without sending in any records, so not sure what exactly they are reviewing) they deem the office visit should not have been charged, they deny. You can send in records to support the EMN charge and modifier 25 usage and appeal.
The denial we receive states: "The benefit for this service is included in the payment/allowance for another service/procedure that as already been adjudicated." Please note this is when we bill an EMN with sometimes SEVERAL different ICD 10 codes than the procedure and the ICD 10 codes are completely unrelated. For example, a patient comes in for a complete skin exam. The provider notes several different issues from freckles, acne, sun spots, sun damage, benign growths on the skin, etc.... spends time with the patient explaining all the issues (causes, preventative measures, etc), treatment methods, prescribing various medications etc. and then will freeze a wart or biopsy a suspected skin cancer spot. They will pay the procedure but deny the office visit stating the above reason. We are not using the same diagnosis for the EMN as the procedure. We send in records that clearly show the EMN is separate from the procedure and we don't hear anything back. When we call we are told usage of the modifier 25 is not appropriate to use in this case and we have to fill out an appeal form, and send in records again. We have quite a few we have appealed but haven't heard back yet.
When we bill an EMN, use mod 25 and charge a minor procedure, should we just send the claim to paper and automatically send in records?