Wiki Well woman exam with flu shot

[mcaster14@gmail.com]

When we bill a Well woman exam with a flu shot we are getting a CCI edit from one insurance company (UHC). All other insurance companies are paying all lines at 100%. UHC states that the WWE cpt code (99395) and the immunization code (90471) are unbundled when reported separately. They are paying for the 90471 and writing off the 99395. I have talked to our representative and she states this an be corrected, but can not tell me how. Is anyone else having this issue with UHC? If so how are you correcting the claim? I also find it odd that other insurance companies are paying this and only UHC is denying it.

 

[Amanda.Kane]

Some insurance companies seem to be pickier with the CCI edits then others.

According to AAPC Coder there is a CCI edit with those codes:

Code 99395 is a column 2 code for 90471 , but a modifier is allowed in order to differentiate between the services provided.
*Use modifier with code 99395

Note*: Always use modifier (if allowable) with column 2 code.

The current NCCI-associated modifiers are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, LM, RC, RI, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, XE, XP, XS, XU, 24, 25, 27, 57, 58, 59, 78, 79, and 91. Read about modifiers for CPT and HCPCS codes

CCI edit Rule: CPT Manual or CMS manual coding instructions *

In the CPT book it states the "If a significantly seperately identifiable E&M service (eg, office or other outpatient services, preventative medicine services) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration code."

According to the above you are correct to submit them individually and I would try resubmitting with a modifier on the 99395 code. Unfortunatly, for coders it is a guessing game as to what the insurance wants as they will not usually give you the answer.

Let us know the outcome!

Hope this helps!
Amanda Kane, CPC, COBGC