Multiple E&M services on the same day
• Reimbursement will be made for a preventive code with a problem focused code when modifier -25 is applied to the problem-focused code. Reimbursement for the preventive service will be made at 100% of the contracted rate, and reimbursement for the problem focused service will be made at 50% of the contracted rate. This should only occur when a significant abnormality or pre-existing condition is addressed and additional work is required to perform the key components of a problem focused E&M service. Members have no copayment and/or deductible for routine physical exams. Members will be responsible for a copayment and/or deductible when a problem-focused code with modifier -25 is included on the claim. Therefore, the appropriate use of modifier -25 is critical since it will be transparent to members. Those services coded with modifier -25 will be regularly reviewed for coding accuracy.
• For all other services, FCHP allows one E&M code per day of service per physician group, per specialty regardless of the places of service.
E&M services submitted with Medicare annual wellness visit
Problem-focused E&M services will be allowed at 50% of the contracted rate when submitted with Medicare annual wellness visit codes G0438 or G0439 when modifier -25 is applied to the problem-focused code. This should only occur when a significant abnormality or pre-existing condition is addressed and additional work is required to perform the key components of a problem focused service. Members will be responsible for a copayment when a problem-focused code with modifier -25 is included on the claim. Therefore, the appropriate use of modifier -25 is critical since it will be transparent to members. Those services coded with modifier -25 will be regularly reviewed for coding accuracy.
E&M services provided with removal of impacted cerumen
FCHP does not reimburse removal of impacted cerumen (69210) when submitted when billed on the same date of service as E&M services.
E&M services provided with an office/outpatient procedure
• FCHP does not allow the separate reimbursement of E&M services when a substantial diagnostic or therapeutic procedure is performed. The “usual care” for the typical patient is already covered by the procedure.
• Append modifier -25 to the E&M service when a significant, separately identifiable E&M service is above and beyond the usual pre- and post-operative procedure rendered by the same physician on the same day as the procedure. Those services coded with modifier -25 will be reimbursed and will be regularly reviewed for coding accuracy.
E&M services provided with lab collection and screening services
• FCHP will not reimburse for G0102 (manual rectal neoplasm screening) when billed on the same date of service as a preventive medicine service (99381-87; 99391-97; S0610; S0612) regardless of location.
• FCHP will not reimburse for Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) when billed on the same date of service as a preventive medicine service (99381-87; 99391-97; S0610; S0612) regardless of location.
• FCHP will not reimburse for G0102 (manual rectal neoplasm screening) when billed on the same date of service as an E&M service (99201-05; 99211-15) regardless of location.
• FCHP will reimburse only non-OBGYN PCPs for G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) when billed on the same date of service as an E&M service (99201-05; 99211-15) regardless of location.
• FCHP will not reimburse for Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) when billed on the same date of service as an E&M service (99201-05; 99211-15) regardless of location.
• FCHP will not reimburse separately for 36415 (collection of venous blood by venipuncture) and/or 36416 (collection of capillary blood specimen i.e., finger, heel, ear stick) when billed along with an E&M office visit (99201-05; 99211-15) or preventative medicine service (99381-87; 99391-97) or office-based lab Proceure codes (i.e. CLIA waived tests).
• FCHP will not reimburse separately for 99000; 99001 (lab specimen handling services) when billed with an E&M office visit (99201-05; 99211-15) or preventive medicine service (99381-87; 99391-97).
• FCHP does reimburse 36415 when it is the sole service provided.
• FCHP does reimburse 36416 when it is the sole service provided.
Medical billing cpt modifiers with procedure codes example. Modifier 59, Modifier 25, modifier 51, modifier 76, modifier 57, modifier 26 & TC, evaluation and management billing modifier and all modifier in Medical billing. Modifier code list. How to use the correct modifier. HCPCS Modifier for radiology, surgery and emergency.
Sunday, October 23, 2016
Modifier 25 and E & M services
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