Wiki Procedure code incidental to primary procedure denials

[pamart@centurylink.net]

I have researched and contacted the payer but to no avail. We are getting denials on E&M codes any when billed with any minor procedure (not planned) saying it is incidental to primary procedure. Modifier -25 is appended the office visit, separate, significant DX codes. Payer states “you can appeal” but I want to know why in the last 60 days this denial is popping up? They cannot give me an answer. Any ideas? Am I missing something? NCCI edits checker shows adding -25 to E&M to override

 

[csperoni]

My guess is a new carrier policy. I know one of the majors (maybe Aetna or Cigna) issued a letter stating they were going to automatically deny any E/M -25 with procedure. Appeal and records would need to be sent. For whatever reason, they decided to delay implementing. For whatever carrier you are receiving denials, check their recent policies on the website. Or monthly newsletters.
While I don't agree with blanket policies like this, I will concede that -25 tends to be an misunderstood/overused/abused modifier.

 

[amyjph]

Agree w/ Christine. Their system is probably now configured to kick out any E/M w/ modifier 25 and a procedure automatically. It's probably the biggest audit target out there in the office POS.

 

[amyjph]

https://providernews.anthem.com/wisconsin/article/update-em-with-modifier-25-same-day-as-procedure-when-a-prior-em-for-the-same-or-similar-service-has-occurred-professional

https://rtwelter.com/blog/2022/07/27/cigna-modifier-25-reimbursement-policy/#:~:text=In%20May%202022%2C%20Cigna%20announced,the%20same%20date%20of%20service.

 

[pamart@centurylink.net]

My guess is a new carrier policy. I know one of the majors (maybe Aetna or Cigna) issued a letter stating they were going to automatically deny any E/M -25 with procedure. Appeal and records would need to be sent. For whatever reason, they decided to delay implementing. For whatever carrier you are receiving denials, check their recent policies on the website. Or monthly newsletters.
While I don't agree with blanket policies like this, I will concede that -25 tends to be an misunderstood/overused/abused modifier.

Thank you. I did look on carriers website. Reviewed all policy updates, even contacted provider line. No one could give me a definitive answer. Frustrating

 

[pamart@centurylink.net]

https://providernews.anthem.com/wisconsin/article/update-em-with-modifier-25-same-day-as-procedure-when-a-prior-em-for-the-same-or-similar-service-has-occurred-professional

https://rtwelter.com/blog/2022/07/27/cigna-modifier-25-reimbursement-policy/#:~:text=In%20May%202022%2C%20Cigna%20announced,the%20same%20date%20of%20service.

Thanks for this information. I am aware of this policy. In this case patient, came in for HBP concern and the "while I am here can you check this...." which resulted in a minor procedure, not related, not planned. E&M denied

 

[csperoni]

Thanks for this information. I am aware of this policy. In this case patient, came in for HBP concern and the "while I am here can you check this...." which resulted in a minor procedure, not related, not planned. E&M denied

While this is frustrating that you have to spend time and resources to get proper payment for services properly billed, my best advice is to spend that time. If carriers are seeing that providers ARE properly using -25, and carriers see they must spend their own time and resources to reprocess and pay, my hope is they will reconsider blanket policies like this.
Again, just my opinion, but what carriers should do is an audit of providers using -25. If they determine a provider is using it correctly 99% of the time, no need to deny future claims. If they determine a different provider is using it correctly only 30% of the time, then only that provider's claims should require appeal.
Just like carriers that notify you a provider is "outside the bell curve" of high level visits, as long as the services are properly coded the first go around, keep hounding them for your proper payment.

 

[pamart@centurylink.net]

While this is frustrating that you have to spend time and resources to get proper payment for services properly billed, my best advice is to spend that time. If carriers are seeing that providers ARE properly using -25, and carriers see they must spend their own time and resources to reprocess and pay, my hope is they will reconsider blanket policies like this.
Again, just my opinion, but what carriers should do is an audit of providers using -25. If they determine a provider is using it correctly 99% of the time, no need to deny future claims. If they determine a different provider is using it correctly only 30% of the time, then only that provider's claims should require appeal.
Just like carriers that notify you a provider is "outside the bell curve" of high level visits, as long as the services are properly coded the first go around, keep hounding them for your proper payment.

Thank you! Nothing I love more than getting denials overturned!