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Kristin Posted Thu 31st of May, 2012 20:54:03 PM

Our office is staffed with one physician and 2 mid level providers. Our physician recently performed a lip excision on a patient. This particular CPT code has a 90 global(40814). The patient came back in within these 90 days for otorrhagia(388.69) which was unrelated to surgery, but was seen by the nurse practitioner. We appended the '24' modifier, but it is still denying because the '24' states the service was performed by the same physician. Since this is a Medicaid claim, we must bill under our NP's Medicaid number. Is there any other way we can get this paid?

SuperCoder Answered Fri 01st of June, 2012 21:46:24 PM

Kayla, If these are different NPIs and the insurer does not consider the NP to be the same physician (supporting modifier 24), then no modifier should be needed. The NPIs tell that it is a different provider type. Usually, the different NPI type is sufficient to file an unrelated EM and still have it counted as the same physician. Have you had this issue before and billed with no modifier?

Otherwise, you need to appeal the decision and submit an explanation. Since CPT considers NPs part of "physician" definition and therefore in the same group, they are essentially the same physician, making 24 correct. You should include CPT's physician definition.

If the above does not overturn the denial and this is a continuing high-volume problem, you may need to consider having the physician provide the unrelated E/M.

Jen Godreau, CPC, CPMA, CPEDC

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