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Natasha Posted 1 Year(s) ago
I am a developmental pediatrician. I do both a medical evaluation and developmental testing. Coders have previously told me that I can charge a 99205 and a 96116 with a 25 modifier on the same day and get paid for both. My evaluations take 90-120 minutes when doing both. Some insurances pay these together, but my main insurance from which I get paid, Regence Blue Cross Blue Shield of Washington, insists that they cannot pay me for both on the same day. The person on the phone suggested I discuss this with a coder. They will pay the questionnaire code 96127 on the same day. Please help! I am getting paid abysmally for the time I'm putting in.
SuperCoder Posted 1 Year(s) ago

Hi Natasha,

As per NCCI edits CPT 99205 and 96116 bundles with each other, but is allowed when modifier is used. However, you may need to check with your document if they support modifier, secondly you may also need to check with the payer policy (BCBS). Please feel free to ask for further query.

SuperCoder Posted 1 Year(s) ago

Hi Natasha,

As per coding guidelines, to bill an Evaluation and management code on the same day as that of the testing, you need to make sure, E&M service performed on that day is a separately identifiable service and is not related to the testing performed on that day. If the evaluation management service was performed for the same problem for which testing is being performed, insurance company will deny the E&M service as it is considered inclusive in the testing performed on that day. 

The point to focus here is that evaluation and management service should not be related to the testing service. It should be a separately identifiable E&M service for a problem unrelated to the current problem for which testing is being performed. 25 modifier should be appended to E&M service code.  

You can report an E/M service with 96127 as there are no bundling issues. Hence, both can be billed together. There is no need to append modifier 25 in this case. 

Hope, the provided information would be helpful. Let me know in case of any further questions.


Posted by Natasha, 1 Year(s). There are 3 posts. The latest reply is from SuperCoder.

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