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OT 97165 and 96111

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June Lawrenz:
Speech therapy clinic that has just taken on an OT. Therapist sent me 97165 (OT Eval) with 96111 (extended testing). Not sure if I misread or misunderstood the CCI tables, but billed 96111 as the primary CPT (from column 1), and was told by a fellow biller to use Modifier 59 on each line (column 2 shows Modifier is allowable with 97165). Insurance paid 96111 but denied 97165 as "service is included in the payment/allowance for another service". Of course the insurance gives the standard response of "we aren't allowed to tell you how to code" so I'm struggling to figure out where my error is. Any advice?

Michele:
I have not billed those codes together but I would have billed the 97165 as the primary CPT with the 96111 using the 59 modifier.  (I am not a certified coder)  I would not have put the 59 modifier on both lines. 

June Lawrenz:
I'm not a coder either, certified or otherwise. Logically, that's how you stated it is what we thought it should be as well, because 96111 reads as  "extended testing". It made sense that the 97165 Evaluation would be first. However, the CCI tables showed 96111 in Column 1, with 97165-59 in column two. I did place the 59 on both lines. I'm hoping to file an Appeal, but not sure how that will play out. Thank you for your input.

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