Wiki Reimbursement for OV with a wellness exam

[tlwright70]

Is anyone having problems with an OV (99212-99215) being paid when billed with a wellness exam. Modifier 25 was used with the dx being encounter for routine child health examination with abnormal findings and the diagnoses as secondary for the abnormal findings. Insurance denied the OV as being included in the payment for another service. Under appeal they upheld their denial stating separate reimbursement is not allowed for the lesser level E/M service code and providers should select a level of service representative of the combined services and submit the appropriate code for that level.

This is how we have been coding an OV with a preventative and have had no problems with reimbursement. Is anyone having this same issue and have any input?

Thanks,

Tina
CPC

 

[mitchellde]

what dx codes did you use, and how were they linked to the CPT codes?

 

[tlwright70]

I just looked at that one again and realized he coded it wrong. However, I just had another deny. It was an established preventative with dx of encounter of child health examination with abnormal findings and nodule of neck as second dx with an OV for it. The dx is assigned correctly for the preventative and the OV assigned to the nodule of neck. Labs and a referral to a specialist was completed for the nodule of neck. Insurance is denying the OV as being included in the primary code. Any input?