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Posted By Deborah Roorda on 03-05-2019, 09:18:28 in Ob-Gyn
We are getting denial when a patient comes for a physical and also is treated for a problem visit. Modifier 25 is used on problem visit and documentation supports CPT code. Is anyone else having this problem? Or does anyone know how to solve this problem or where I can get more information regarding this?
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Posted By Melanie Witt on 03-06-2019, 15:22:34
As your title seems to imply you are getting an actual denial message, what is that message (the 835 electronic data interchange is the source for the remittance advice codes)? This will tell you what the payer is objecting to. While CPT clearly states you can bill for both, it is my experience that many payers will only pay for one E/M code on a date of service and usually they will end up paying for the one that is the least costly. While Aetna agreed to stop bundling problem-oriented services with preventive services provided on the same date back in 2006, more than 40 other health plans continue to do so. Bottom line, you need to know the payer policy. If they say they pay for both and you have a denial, appeal. If they say they do not, make sure that the patient is informed and schedule her for a problem service visit either before or after the preventive medicine service.
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