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cpt 99213 denied due to one of the ICD denying off the mod 25

Fion Posted Thu 11th of February, 2016 12:03:15 PM

I have denied claim from the wellcare, the claim has been denied by the reason:cpt 99213 denied due to one of the ICD denying off the mod 25

Age:65Y Sex:F
1. Acute nasopharyngitis [common cold] - J00 (Primary)
2. Chronic rhinitis - J31.0
3. Encounter for immunization - Z23
4. Disorder of bone density and structure, unspecified - M85.9
5. Pain in right thigh - M79.651
6. Essential (primary) hypertension - I10
7. Body mass index (BMI) 24.0-24.9, adult - Z68.24

cpt billed
99213 modifier 25 icd pointer: 1,2,3,4 cpt denied
Q2038 icd pointer:3 paid
G0008 icd pointer:3 Paid

Please let me know whicd icd is denying the mod 25. Thank you!

SuperCoder Answered Fri 12th of February, 2016 03:18:45 AM

With the information provided, it is difficult to say which particular ICD denied modifier 25. However the following points might be helpful for you, as these are examples of misuses of mod 25 that may lead to its denial:
• reporting an E/M service that resulted in the decision to perform major surgery
• using mod 25 on an E/M service that was performed on a different day than a procedure
• applying surgical codes (10021 to 69990); and
• billing an E/M service with mod 25 when a patient’s visit to the physician was particularly for a scheduled minor procedure (No separately identifiable E/M service was performed)
If we talk about the appropriate usage of mod 25, then remember that if you don't have a history, exam and medical decision–making (HEM), you can't bill an E/M. All procedures include some service related to patient evaluation and management, but a separate E/M should include its own HEM. In other words, the physician needs to determine whether the problem is significant enough to require additional work to perform the key components of the problem–oriented E/M service.

Fion Posted Wed 17th of February, 2016 14:09:28 PM

Thank you so much for E/M with Mod 25 requirements.

SuperCoder Answered Wed 17th of February, 2016 23:46:29 PM

Happy to Help!

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