Wiki Professional Fees Billing

[Barbaraj6]

This is new to me as I have not had to deal with group therapy coding along with the E/M coding. According to the NCCI edit, a group therapy session cannot be billed on the same day as a subsequent hospital visit. However, the listing also states that the use of a modifier is acceptable. Prior to my starting this, the physician group's biller used modifier -25 on the E/M service and was paid for both codes. Within the last few months, it has changed and most payers are only reimbursing for one code or the other; sometimes the group and sometimes the E/M service. Does anyone have any experience with this? Maybe you could provide a bit of insight into this? Thanks!

 

[Cavalier40]

Well I guess the first question to ask is if the group therapy sessions are part of a facility based treatment program and why are they being billed on the professional form? That might clarify whether or not you should be billing for the code.

 

[Barbaraj6]

I understand what you are saying. The agreement is that our providers will oversee and conduct the group therapy sessions for the patients on the unit. The professional fees are not included in the hospital contracts with the payers hence our group bills the 90853. We have some payers who pay both the subsequent visit as well as the group charge while others will pay one or the other-no matter if a modifier is present or not.