Billing and coding tricks

From: Seto Gary <glseto@mac.com>
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Date: Tue, 12 Sep 2006 08:19:41 -0700
Subject: Re: [Practiceimprovement1] Re: Supply/Demand, Chronic FU visits, coding coun...
Reply-To: Practiceimprovement1@yahoogroups.com

Kristin,

I've come to look upon medical claims coding as a game, one in which the insurance companies know the rules, but we don't. By trial and error, I've figured out that some insurers won't pay for a visit if it seems solely like a mental health or counselling visit. But if you place a non-psychiatric ICD9 code as the top code, it does go through. For example, if you list your ICD9 codes as:

1. 311 Depression

2. 401.9 Hypertension

some insurers will deny it. If you reverse the order and resubmit as a new or corrected claim:

1. 401.9 Hypertension

2. 311 Depression

they will pay it. I had another insurer deny a visit for "524.60 TMJ Syndrome" because they said they didn't cover dental problems. I recoded it as "388.70 Otalgia" (well, the chief complaint was ear pain) and it went through. I'm sure there are others on the listserve who have learned similar ways of "creative coding". Still, it is frustrating the amount of hoops and contortions we must go through in order to be paid.

Gary Seto

South Pasadena, CA

From: Marion Bobb-McKoy <redesigntime@yahoo.com>
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Date: Tue, 12 Sep 2006 21:15:32 -0700 (PDT)
Subject: RE: [Practiceimprovement1] Re: Supply/Demand, Chronic FU visits, coding coun...
Reply-To: Practiceimprovement1@yahoogroups.com

Along the same lines. I have been getting denied abut 80 % of the time using the the modifier -25. I have been trying to creatively figure out how to maximally, financially construct visits. Most of the patients I see for the first time come in as physicals, but end up having some issue, hence modifier -25. For females, I defer the gyn exam for a second visit and can also discuss lab work at that visit. Any thoughts at doing a better way?

Marion

From: Nancy Guinn <NGuinn555@comcast.net>
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Date: Tue, 12 Sep 2006 23:08:02 -0600
Subject: Re: [Practiceimprovement1] Re: Supply/Demand, Chronic FU visits, coding coun...
Reply-To: Practiceimprovement1@yahoogroups.com

United and Cigna usually or always deny modifier 25 claims, even with a written appeal (United will change that in a miserly way in 2007).

Most of my other insurers pay it, some, for instance BCBS routinely, others only after receiving a written appeal which includes a note that has separate sections for the preventive and E/M interactions. My practice is a little abnormal in terms of nationals stats, as about 1/3 of my patients are insured by a very powerful local HMO. Other folks could comment on the other big companies you may see.

Nancy

From: Seto Gary <glseto@mac.com>
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Date: Tue, 12 Sep 2006 22:42:38 -0700
Subject: Re: [Practiceimprovement1] Re: Supply/Demand, Chronic FU visits, coding coun...
Reply-To: Practiceimprovement1@yahoogroups.com

Marion,

I don't know which insurers are denying your claims using modifier -25, but I have been paid by Blue Cross/Blue Shield and Aetna when I use -25. Like Nancy, I have been stiffed by United Healthcare and Cigna. I found this webpage which offered some helpful advice on how to get paid for a -25 visit: http://www.thecodingcenter.org/paper/10-01-a.html

Anytime you submit a visit with a -25 modifier you need to submit a copy of the office note (if you don't submit the note the visit will be automatically denied).
The exception to this rule is for New Patient and Consultation visits, which do not require the use of modifier -25, but if you do use the modifier, notes are not required.
If the note is attached, your claim is sent to a nurse reviewer who based on certain criteria will determine if the visit is significant and separately identifiable. It will be paid or denied accordingly.
The criteria was defined in this way, "once the usual services that are required of the procedure and the procedure itself are removed from the note (i.e. the necessary exam and affiliated services) ...do the remaining notes stand on their own and separately address the key components required for the reporting of that level of service?"
If the visit is denied you have the right to request an appeal at which time the Medical Director gets involved in the review.
Common reasons for denial are; the note doesn't meet documentation standards, the notes indicate the patient is returning for a continuation of treatment but no re-evaluation is done.

I think I will try sending appeals with an attached office note and see what happens.

Gary Seto

South Pasadena, CA

From: "David Brock DO" <drbrock@rrohio.com>
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Date: Thu, 14 Sep 2006 12:33:45 -0400
Subject: RE: [Practiceimprovement1] Re: Supply/Demand, Chronic FU visits, coding coun...
Reply-To: Practiceimprovement1@yahoogroups.com

Yes, that may be the case. I essentially never code a preventive & acute E/M on the same day, & rarely do preventives (a handful per month maybe). I will check re: other procedure + E/M + 25 modifier, but I’m almost certain UHC pays these. Ohio Medicaid is the only one I’ve found that rejects the 25 modifier claims.

David

From: Rocky Patel <drrcpatel@yahoo.com>
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Date: Thu, 14 Sep 2006 09:16:31 -0700 (PDT)
Subject: RE: [Practiceimprovement1] Re: Supply/Demand, Chronic FU visits, coding coun...
Reply-To: Practiceimprovement1@yahoogroups.com

David,

I am very interested what you are doing to get lesion removal and E/M
paid together on UHC. Could you pull an EOB or 2 and post how that is
being coded and with CPT/ICD-9 codes.

UHC has not been doing this for us.

Inquiring minds want to know

rocky

From: "David Brock DO" <drbrock@rrohio.com>
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Date: Thu, 14 Sep 2006 14:41:38 -0400
Subject: RE: [Practiceimprovement1] Re: Supply/Demand, Chronic FU visits, coding coun...
Reply-To: Practiceimprovement1@yahoogroups.com

I do not do preventives + acute E/M on same day, so that I am unable to comment on. But just today I saw a lady for skin lesions, turned out to be inflamed skin tags. My ICD-9 was 701.9, E/M was 99212 with -25 modifier attached, followed by procedural codes 17000 & 17003 (cryo x 12 lesions total). I assure you that both will be paid by UHC, they almost always are. I’m not sure what you may be doing differently, different geographic area, etc?

David

From: mkcl6@aol.com
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Date: Fri, 15 Sep 2006 06:56:37 EDT
Subject: Re: [Practiceimprovement1] Re: Supply/Demand, Chronic FU visits, coding coun...
Reply-To: Practiceimprovement1@yahoogroups.com

I just remembered one critical difference. One of the big employers nearby is JP Morgan Chase, the other Cardinal Health. They both have chosen insurance coverage for their employees that allows for their preventative care to be covered at 100 percent while their acute care comes from a health care savings acct. the employer has funded. That's why they all call wanting physicals. Usually I get to the real issue in the first 30sec of the appt. Kristin