Wiki Modifier Question

[ametcalf@intermed.com]

Hi
I have some claims that I am struggling with and wondering if someone could help me on how what to add for modifiers:
I have CPT codes 99397, 99212, G0402, 17110, 90732 and G0009 and I usually add the 25 Modifier to 99397 and 99213 because there is a procedure code and immunization. The G0402 CPT code always gets denied by Medicare advantage plans stating that it is incidental to the Primary procedure. All the other CPT codes are paid. Can someone advise on what I would need to do to get all codes paid including the G0402- Feeling lost. Thank you so much.
August Metcalf

 

[haraml7]

G0402 IS 99397, the G code is only for Medicare patients (in certain circumstances) and depending on what insurance company the Medicare Advantage plan is with they may not accept the G0402. This goes for G0009 (administration of the drug) as well.

In the Medicare guidelines, this is considered a Welcome to Medicare code. This code (G0402) is when they are in their first 12 months of Medicare. Medicare advantage plan are separate plans from traditional Medicare. Like, if this patient has a Medicare advantage plan with BCBS you would follow BCBS guidelines for preventative visits.

Also, the 99397 code is for an established preventative visit.

Are you also billing for a 99212 with the 99397 or were you just giving several examples for office visit scenarios.

 

[taysin93]

For Medicare AWV + O/V
G0468+G0438 New P/E
G0468+G0439 Est. P/E
99213+G0468 Est. O/V
99203+G0466 New O/V
G0008 for Flu shot
G0009 Pneumococcal