Fion Posted Wed 13th of April, 2016 10:30:45 AM
I have a denied claim for the Fidelis member, patient was discharged from the hospital on Dec 15th, 2015. After she discharged from the hospital, she came to the clinic, for refill some medications. the claim has been denied as:Place of Service not consistent with another claim. we have verified with the insurance plan, I was been told that patient discharged from the hospital on the same day, that's why the outpatient office visit claim has been denied. Can you help me look into the problem, is that possible to append the modifier on the E/M code? The modifier 25 doesn't work.
SuperCoder Answered Thu 14th of April, 2016 01:49:58 AM
If the patient was seen by the same physician in office and for hospital discharge management services, you cannot report the office visit E/M code separately. It is considered included in the higher level of E/M services which is discharge management services here. You can code the higher level of hospital discharge day management services by including the time spent in drug prescription or refilling, but you cannot report 2 E/M code on same DOS.
Fion Posted Mon 18th of April, 2016 15:18:26 PM
I'm sorry for the confusion. patient was seem by different provider on the same day, Can you let me know how should I claim for this outpatient office visit.Thank you!
SuperCoder Answered Mon 18th of April, 2016 23:49:59 PM
If both the providers (Hospital discharge managing doctor and clinic doctor) belongs to same TIN, then you cannot bill for clinic visit separately. If they belongs to different, then you can bill for clinic visit with appropriate place of service (POS).
Fion Posted Tue 26th of April, 2016 08:57:43 AM
the both the providers (Hospital discharge managing doctor and clinic doctor)are not belongs to same TIN, we billed for clinic visit with appropriate place of service (POS)- 11, date of service on:12/15/2015.but the claim has been denied by the following reason:The procedure code/bill type is inconsistent with the place of service. the insurance says patient had hospital visit 12/11/205-12/15/2016. Patient was discharge from the hosptial at the same day. that's why the out patient office is denied. is that reasonable? should I appeal for it?
SuperCoder Answered Tue 26th of April, 2016 23:53:56 PM
We would suggest you to contact the Insurance carrier and get the medical or billing policy/document which support their denial reason. If they fail to provide, you can go for appeal.