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99242 denied by work comp when billed with 95903 and 95904

Pauline Posted Thu 05th of December, 2013 11:42:06 AM

Work Comp denied 99242 when billed with 95903 and 95904 stating that 99242 is bundled. I can't find information to confirm this.
Can you confirm this and direct me to documentation confirming this?

SuperCoder Answered Thu 05th of December, 2013 22:12:34 PM

This particular workers' compensation jurisdiction must be using prior year codes as the 95903 & 95904 codes were deleted effective Jan 1, 2013.

That plus that Medicare doesn't cover the consultation codes is likely why you aren't finding any Medicare NCCI bundling edits on the codes. However, historically even when these nerve conduction study codes were in effect, then did not have bundling edits with any of the E/M codes.

However, there is no requirement that Workers' compensation must use the Medicare bundling edits but rather may use their own proprietary bundling edits to determine what is included in the specific codes, etc. So for this particular payer the provider may need to append modifier 25 IF the documentation supports that it is separately identifiable from the low level history and low level exam that is considered to be part of the electrodiagnostic studies.

The Neurology and Neuromuscular section guidelines include the following:
Neurologic services are typically consultative, and any of the levels of consultation (99241-99255) may be appropriate.

In addition, services and skills outlined under Evaluation and Management levels of service appropriate to neurologic illnesses should be similarly reported. ...
which can be used to assist in the denial appeal IF the documentation does indicate that the physician did perform and document the services to support the use of modifier 25 with the consultation code.

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