Medical Billing Forum

Billing => Billing => Topic started by: best biller on February 06, 2014, 12:10:29 PM

Title: Re: billing 99354
Post by: best biller on February 06, 2014, 12:10:29 PM
i would like to know with which modifier 99354 she be billed. ins denies incorrect modifier
thanks in advance
Title: Re: billing 99354
Post by: Michele on February 07, 2014, 09:38:07 AM
There is no way to know without more info.  Also, I hate to sound like a broken record but it is not OK for a biller to simply change a modifier to get the claim paid.  Modifiers are part of coding and in order to code you must have access to ALL of the information.  But even based on your question you don't say what modifier was on it that was denied.

Need way more info.

Title: Re: billing 99354
Post by: best biller on February 14, 2014, 09:41:55 AM
modifier 59
Title: Re: billing 99354
Post by: Michele on February 14, 2014, 10:42:28 AM
If you are using 59 modifier then there must be other codes on the claim?
Title: Re: billing 99354
Post by: shanbull on February 14, 2014, 10:43:27 AM
Was this billed with an E&M code too? In that case the modifier would need to be on the E&M code rather than the additional service. And I would not use modifier 59. Here's why: http://www.poweryourpractice.com/revenue-cycle-management/modifier-59-25-91-guide-coders/ (http://www.poweryourpractice.com/revenue-cycle-management/modifier-59-25-91-guide-coders/)

Usually for E&M services with extra components we're talking about an additional service for a condition that requires extra diagnostic or counseling time, not an additional body part. Modifier 59 is used to identify a service performed on a different body part than the main examination covered. If this does not apply, you should not use modifier 59.
Title: Re: billing 99354
Post by: best biller on February 18, 2014, 10:37:11 AM
i used modifier 25 on the 99214 and 59 on 99354
Title: Re: billing 99354
Post by: shanbull on February 18, 2014, 12:28:24 PM
I would just delete the 59 modifier and resubmit the claim, the modifier 25 on the E&M is sufficient to separate the two services.
Title: Re: billing 99354
Post by: best biller on February 24, 2014, 12:11:50 PM
i tried that for a different patient and it didn't work either
Title: Re: billing 99354
Post by: shanbull on February 24, 2014, 02:08:24 PM
i tried that for a different patient and it didn't work either

What insurance company is this for? I just looked through the Medicare publication about this and your CPT's should be fine to bill together and both be paid. Your exact scenario is in this coding example as well: http://www.findacode.com/articles/prolonged-evaluation-and-management-em-services-99354-99355.html (http://www.findacode.com/articles/prolonged-evaluation-and-management-em-services-99354-99355.html)

So at this point I'm thinking maybe it's the insurer that has special rules? Because from a coding standpoint, what you're submitting is correct as far as I can tell, unless I'm missing a crucial detail here.
Title: Re: billing 99354
Post by: dermbillerPA on February 26, 2014, 09:49:28 AM
It is my understanding that NO modifiers are required if your billing 99214 with 99354.
Title: Re: billing 99354
Post by: Michele on February 27, 2014, 10:32:15 AM
I like to start out by stating that I am not a certified coder.  With that being said,

The definition of the 25 modifier is :  significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service

Since the 99354 is not a separate service, but actually further explaining the 99214 I do not believe it would be appropriate.
Title: Re: billing 99354
Post by: best biller on March 19, 2014, 09:56:30 AM
empire plan denied 59 modifier, the provider is out of network
Title: Re: billing 99354
Post by: Michele on March 19, 2014, 11:06:27 AM
If provider is out of network he shouldn't even be getting the eobs.  Patient would be responsible for fighting any claim issues, wouldn't they?
Title: Re: billing 99354
Post by: PMRNC on March 19, 2014, 02:22:36 PM

Quote
If provider is out of network he shouldn't even be getting the eobs.  Patient would be responsible for fighting any claim issues, wouldn't they?

I have clients out of network with some plans that still do an AOB and get the EOB. Yes in simple terms a patient should be responsible for fighting SOME claims denials (ERISA claims must be appealed by patient anyway) but most times if there is an assignment of benefits on file and this is a denial based on medical necessity or any other reason involving clinical information it is in the providers best interest to head the appeal.
Title: Re: billing 99354
Post by: Michele on March 20, 2014, 09:30:01 AM
Yes, in some cases they will still receive the EOB.  But we bill a lot of Empire Plan claims, in fact I have my insurance with that plan.  I have never seen them send an EOB to the provider if the provider is out of network.  We actually run into issues with them if the patient has a 2ndary because we need the eob to submit to the 2ndary.  Linda is right, in most cases it is in the provider's best interest to assist patient's in making sure claims were processed correctly.

best biller - after going back and rereading what was written I'm thinking that maybe the problem is that the codes don't require a modifier.  You may want to go back to the coder or provider and ask if the 59 modifier was applied appropriately.
Title: Re: billing 99354
Post by: best biller on March 20, 2014, 07:32:12 PM
thanks to everyone!
firstly i received the eob from the patient and secondly i tried billing without a modifier and was denied for incorrect modifier
Title: Re: billing 99354
Post by: best biller on March 25, 2014, 01:41:40 PM
any suggestions???????????????
Title: Re: billing 99354
Post by: PMRNC on March 25, 2014, 03:32:32 PM
Which line was being denied for incorrect modifier ?   99214 or 99354?
Could your problem be in the "units"?   this may help:    http://ecpmd.com/files/CPT99354_99357.pdf
Title: Re: billing 99354
Post by: best biller on September 10, 2014, 11:57:04 AM
I work in a internal med office and the physician usually bill a 99214 but the time she spend with the patient may be 40-60min and she also may give a b-12 injection, so i add a prlong code 99354 but it is being rejected by the insurance carrier. i usually code it like this:
99214-25
99354
96372-59
J3420

everything is being paid except for the prolong code. am i coding this wrong or missing a modifier, can anyone help?
Title: Re: billing 99354
Post by: kristin on September 10, 2014, 07:26:02 PM
Well, for starters, my understanding is you can't bill the 99354 until you reach a total of 55 minutes for the 99214 visit. That is because you can't count the 25 minutes for the 99214 towards your time, only what comes after, and it has to be face to face from the provider. A patient sitting in a room alone, or seeing someone during the visit other than the provider doesn't count towards the time. So a 40 minute visit won't qualify for the 99354, at all.

Next, different payers have medical policies and coding policies in place for these prolonged visit codes. Have you contacted the insurance companies that are denying your claims, or researched their websites for info on what they require for billing these codes?