Pam Posted Tue 13th of February, 2018 14:16:46 PM
Patient comes to office with cut. We bill an E/M 99214 - 25, adacel 90715, injection fee 96372 - 51 and derma bond g0168. I'm being told the 96372 will not be paid with the G0168 unless a valid modifier is used? Doesn't the 51 cover at? What mod would I use?
SuperCoder Answered Wed 14th of February, 2018 02:12:14 AM
The first reason for denial could be that HCPCS code G0168 is used by Medicare only, often private payers use the CPT simple repair codes, specifically 12001 through 12018. The other reason for denial could be I believe if it is truly a simple repair (such as Dermabond)-the E/M will capture the work for the repair in that case. Or, you could just bill the procedure and not the E/M if the reason for the visit was to treat the laceration-it wasn't as if the patient went in not knowing what needed to be done and the decision was made then and there to repair it. Modifier 25 is used to indicate that, on the day of a procedure or service identified by a CPT code, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided. A significant, separately identifiable E/M service is one with separate documentation of the components of an E/M service. Documentation should be extensive enough that the additional service is readily identifiable. The E/M service must require additional history, exam, knowledge, skill, work time, and/or risk above and beyond what is usually required for the procedure. By definition, the â€œabove and beyondâ€ requires that the evaluation be more than problem focused.
HOPE THIS HELPS!
Pam Posted Wed 14th of February, 2018 09:07:30 AM
There not saying anything regarding the E/M they are saying - the 96372 will not be paid with the G0168 unless a valid modifier is used?
SuperCoder Answered Thu 15th of February, 2018 02:22:41 AM
The administration code for Adacel 90715 should be 90471 and not 96372. CPT code 90471 does not require any modifier to be coded with G0168.
HOPE THIS HELPS!