Medical Billing Forum
Billing => Billing => : dpetras December 08, 2016, 02:11:23 PM
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I have lately been getting this rejection from the payer (either Palmetto for WV or CGS for OH):41 :
"SMARTEDIT MUO PER CCI GUIDELINES PROCEDURE CODE 99212 HAS AN UNBUNDLE RELATIONSHIP WITH PROCEDURE CODE 11721 BILLED FOR THE SAME DATE OF SERVICE. REVIEW DOCUMENTATION TO DETERMINE IF A MODIFIER OVERRIDE IS APPROPRIATE" I'm using Health Fusion software for our podiatry practice. I started out billing the following way: 99212 (25) for diabetes or pain left leg or pain right leg, then 11721 for the B351. Then we we received a letter from Medicare stating they were watching us for too many uses of the 25 modifier, so we started billing this way: 99212 (no modifier) and 11721 (with 59). What is the correct way to bill nails, and how often should we be using the 25 modifier?
Thank you
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You will not be paid for an E/M billed with a procedure code like 11721 if you don't use a 25, 24, or 24/25 combo modifier, IF it is appropriate for the situation. Meaning the E/M is significantly and separately identifiable from the procedure. If it is not, you do not bill the E/M code at all.
The only time you use a 59 modifier is if two or more procedures are done at the same time, and then only if a 59 modifier is allowed to bypass CCI edits, AND appropriate for what was done. In your example, you listed an E/M code, and a procedure code, and you put the 59 modifier on the procedure code...but the problem is there was only one procedure done, the 11721. Therefore, you would never use a 59 in that instance.
So to answer your last two questions, the correct way to bill nails is based on the LCD for your MAC, and you can use a 25 modifier as often as you want, so long as you are using it in the appropriate way.
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Thanks for answering Kristin. So can I use these examples: Pain left leg, pain right leg, nails....11721 only, and choose dx for nails and pain on same line?
We also received a letter from CGS last year that said they were watching us for using too many 25 modifiers, so I started billing the 99212 with B351 and 11721 with B351 and a 59. How do you know when you are using too many 25's? And now, I've seen the payer has recently rejected a bunch of my November claims that were billed this way, which is why I'm wondering about just using the 11721/11720 only and choosing B351 and E119 (or pain) as 2nd dx.
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If you are billing every E&M code with a 25 modifier when there is a 11721/11720 code that will set off flags. Generally speaking (not specific to any of your examples) most patients that come in for Debridement of Nails do not also require an office visit. If they have a separate issue that requires the doctor's attention, or if there was a complicating factor, it might be warranted. So if you received a letter stating you were overusing the 25 modifier you should check into how often that is occurring and if it is being overused. Just because one insurance carrier sent you a letter does not mean it is being overused, but you need to check into it. Putting a modifier on a service just to get paid for it is fraud so you want to make sure that the modifiers were warranted and that the documentation in the chart supports the use of the modifier.
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Thanks for answering Kristin. So can I use these examples: Pain left leg, pain right leg, nails....11721 only, and choose dx for nails and pain on same line?
We also received a letter from CGS last year that said they were watching us for using too many 25 modifiers, so I started billing the 99212 with B351 and 11721 with B351 and a 59. How do you know when you are using too many 25's? And now, I've seen the payer has recently rejected a bunch of my November claims that were billed this way, which is why I'm wondering about just using the 11721/11720 only and choosing B351 and E119 (or pain) as 2nd dx.
1. When billing for debridement of mycotic nails, when the requirements for the LCD are met, your line of service should be the 11720/11721 code, with dx's of B35.1, and then the pain codes for either toe/foot pain(NOT leg pain), either using both left and right for 11721, or the appropriate side if all the nails debrided happen to be on the same foot. My MAC will accept the pains codes first, then the B35.1, yours may want the B35.1 first. This is why you absolutely need to know how the LCD for your MAC reads. The pain codes are as follows:
M79.671 Pain in right foot
M79.672 Pain in left foot
M79.674 Pain in right toe(s)
M79.675 Pain in left toe(s)
If the sole reason a patient is there is to have their nails debrided, and that is all that is done, you would not bill an E/M code also, ever.
2. If I am reading your second question right, you are saying that because certain insurances sent you letters saying that the 25 modifier was being over-utilized, that you decided to bill claims like this:
99212-B35.1
11721-59-B35.1(and maybe pain dx's were used also, I am not sure based on your response)
The problem with above coding is two-fold, and most likely why the claims have been rejected:
1. As I said in my earlier response, you never use a 59 modifier when only one procedure is done. That is an automatic denial.
2. You can't bill a 99212 with or without a 25 using the same dx as for the 11721, because it is not warranted.
3. If only the 11720/11721 is able to be billed, the patient has to fit criteria for medical necessity based on your MAC's LCD. In some cases that will be B35.1 and pain codes, in others it will systemic conditions such as E11.9(need the name/NPI of physician treating the systemic condition such as E11.9 and last date seen by that physician on claims), or you use Q7, Q8, Q9 modifiers with appropriate dx's.
Again, and I cannot stress this enough, you or the doctor(s) you are billing/coding for need to completely familiarize yourselves with the Routine Foot Care/Nail Debridement LCD's for your MAC.
Finally, in regard to when using a 25 modifier is too much, all the podiatrists I bill for only code an E/M with a 25 modifier at the same time they do nail debridements when that E/M code is for any problem(s) the patient may have that is/are unrelated/separate/significantly identifiable from anything to do with the nail debridement, and only when the history/exam/MDM meets the requirements to bill the correct E/M level with a 25 modifier.
They also get letters now and again from Medicare saying that they need to send in tx notes before the E/M with a 25 will be considered, and notes are sent in, and in every instance, the E/M is then paid. This is because they are coding appropriately, and their documentation supports that. So as I said before, there is no such thing as too many 25 modifiers, if they are used in the appropriate way.
Too many doctors/billers/coders panic when they get letters from insurance companies saying they are over-utilizing certain codes/modifiers (and are considered outlier providers, when in fact they are not doing anything wrong), and they think the answer is to change how they code, so as to fall under the radar, and not get further letters. I call BS on that. I tell the doctors I bill for not to be frightened by those letters, because I know they are coding correctly, and their tx notes will and do stand up to any scrutiny/audit.
I have no idea if that is the case with who you are billing/coding for. But the read I am getting from what you have asked is that there are issues with how things are being coded/billed, and the solution is not to change up which dx's go with which CPT codes, and which modifiers are being applied, but rather a very clear understanding of when an E/M code can be billed, and when it cannot be billed. As well as what constitutes a covered nail debridement, and what does not. If that is the case, let me know, I can help you.
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