Medical Billing Forum

Billing => Billing => : dmaney August 03, 2012, 05:14:05 PM

: well visit e/m with sick visit e/m plus mod 25
: dmaney August 03, 2012, 05:14:05 PM
Any advice on billing the following scenarios:
A patient comes in for a well visit and also a sore knee (stated as the reason for visit).  We are getting reimbursed for the well but not the e/m involved in the knee (just an example).  We've been using well e/m plus a sick e/m plus the modifier 25.  No reimbursement for sick e/m.

A patient comes in for a well visit (as stated as the reason for the visit).  During the exam, a suspicious lump is found (now we have a sick visit, right?) Again, we've been using a well e/m plus a sick e/m with modifier 25.  No reimbursement for sick e/m.

Would using modifier 33 for preventative (well) help us to get reimbursed for dr's extra exam and medical decision making?
: Re: well visit e/m with sick visit e/m plus mod 25
: Michele August 05, 2012, 10:19:39 AM
I don't believe the 33 modifier is going to help.  Without knowing the reason that the e&m wasn't paid it is hard to say.  Have you tried calling the insurance carrier to see why the sick portion was not allowed?  It sounds as if it was coded correctly.
: Re: well visit e/m with sick visit e/m plus mod 25
: dmaney August 05, 2012, 11:29:35 AM
Have you been getting paid for sick visits in these circumstances?

Anyone else having this problem?  Or just us?

Will ask person in charge if she has called...
: Re: well visit e/m with sick visit e/m plus mod 25
: Michele August 05, 2012, 05:15:58 PM
If you bill for a well visit, and an E&M with a medical dx using the 25 modifier, they are usually both allowed.  Occasionally there is a plan that does not allow for both a well visit & E&M for sick visit at same time. 
: Re: well visit e/m with sick visit e/m plus mod 25
: deedee August 15, 2012, 12:33:49 AM
it depends on the insurance carrier because as far as I know not all of them allow it. I would check with the insurance carrier.