Author Topic: new mental health billing codes-25 modifier need?  (Read 11924 times)

James B

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new mental health billing codes-25 modifier need?
« on: February 22, 2013, 10:59:26 AM »
I just got all of January's billing out about 10 days ago and am eager to see how the different payers are reimbursing the new codes. Some problems were anticipated, naturally. I've run into my first one:

Anthem told a colleague yesterday that we need to use a 25 modifier when a 99214(modifier applies to this code) is billed along with a 90836. In this case, they actually paid the full amount for all the 99214s I had billed for this patient in Jan but ignored the 90836's that were part of those same appointments. My colleague is telling me to use the 25 modifier whenever an add-on code(99212,99213,99214, etc.) is billed along with a psychotherapy code(90833,90836).

However, it appears that Cigna just paid on a similar claim where no modifier had been used. They paid on both codes. 

Help, please? Is this going to vary depending on the insurer? Should I just use the 25 modifier(except for Medicare) to be safe?

Thanks!

James

PMRNC

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Re: new mental health billing codes-25 modifier need?
« Reply #1 on: February 22, 2013, 11:14:02 AM »
I don't believe you can just arbitrarily assign a modifier if it's not required/necessary unless documentation is required.  I have a tips booklet with tips on modifiers and for -25 it says:

– -25 Significant separately identifiable E/M service by the
same physician on the same day.


– When a physician must provide a separate and identifiable E/M
service on the same day as a procedure or another service,
modifier 25 is appended to the E/M code.

– Both the E/M service and the other service or procedure require
individual documentation, although this documentation may be
within the same written note

TIP

– Ask yourself: “Would a separate visit have been needed to
take care of the problem? Does my documentation (hx,PE,
MDM and/or time) support a separate service?”
Modifier
Linda Walker
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rdmoore2003

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Re: new mental health billing codes-25 modifier need?
« Reply #2 on: February 27, 2013, 03:41:14 PM »
I was told by insurance companies and DHH that with the add on codes- no modifiers are required.  I havent had issues with any except Blue Cross Blue Shield.  They are not wanting E/M with therapy add on (90832, 90834 & 90837).   We are waiting to see if they actually cover the E/M with medication add on (90833, 90836, & 90837)
Regina

James B

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Re: new mental health billing codes-25 modifier need?
« Reply #3 on: February 28, 2013, 03:23:26 PM »
I was told by insurance companies and DHH that with the add on codes- no modifiers are required.  I haven't had issues with any except Blue Cross Blue Shield.  They are not wanting E/M with therapy add on (90832, 90834 & 90837).   We are waiting to see if they actually cover the E/M with medication add on (90833, 90836, & 90837)

This has been our experience, exactly, so far. I'm sure BC/BS is behind close doors figuring out how not to pay psychiatrists, especially OON doctors like us. 90832, 90347, 90837 are for with therapy without E/M.

rdmoore2003

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Re: new mental health billing codes-25 modifier need?
« Reply #4 on: March 06, 2013, 09:57:00 AM »
I havent had issues with any except Blue Cross Blue Shield.  They are not wanting E/M with therapy add on (90832, 90834 & 90837).   We are waiting to see if they actually cover the E/M with medication add on (90833, 90836, & 90837)

BCBS is reimbursing the E/M + 90833, 90836, & 90838
Regina

James B

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Re: new mental health billing codes-25 modifier need?
« Reply #5 on: March 07, 2013, 11:08:23 AM »
That's good to hear. I have been resubmitting my 99213/90836(and similar) appointments with the 25 modifier on the first line ONLY for BC/BS because that is what someone from Anthem told my colleague to do. Has that been your experience? Prior to that, in at least one case, they paid the full amount on line one and completely ignored the therapy code.

With other insurers, in general, we have been seeing some improved reimbursements since the new codes took effect.

James B

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Re: new mental health billing codes-25 modifier need?
« Reply #6 on: March 07, 2013, 12:36:25 PM »
I havent had issues with any except Blue Cross Blue Shield.  They are not wanting E/M with therapy add on (90832, 90834 & 90837).   We are waiting to see if they actually cover the E/M with medication add on (90833, 90836, & 90837)

BCBS is reimbursing the E/M + 90833, 90836, & 90838

I'm looking at an ERA indicating that they paid the first line(99214) in full but completely ignored the second line(90836). I'm going to have to call them.

PMRNC

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Re: new mental health billing codes-25 modifier need?
« Reply #7 on: March 07, 2013, 01:05:09 PM »
Quote
That's good to hear. I have been resubmitting my 99213/90836(and similar) appointments with the 25 modifier on the first line ONLY for BC/BS because that is what someone from Anthem told my colleague to do. Has that been your experience? Prior to that, in at least one case, they paid the full amount on line one and completely ignored the therapy code.


Carriers are not supposed to tell you how to code and they should not be telling you to arbitrarily assign modifier 25, that's incorrect. Modifier 25 is ONLY for when there is   "Significant separately identifiable E/M service by the same physician on the same day."  Arbitrarily/routinely assigning this modifier is going to trigger a red flag. Where you assigned a modifier 25 I would hope documentation is going to show that it was a significant and separately identifiable service
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

rdmoore2003

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Re: new mental health billing codes-25 modifier need?
« Reply #8 on: March 07, 2013, 03:27:36 PM »

I'm looking at an ERA indicating that they paid the first line(99214) in full but completely ignored the second line(90836). I'm going to have to call them.

Blue Cross will not reimburse an E/M code with a therapy add on code.  ex:  99214 + 90834    Blue Cross will reimburse E/M code with a medication add on code ex:  99214 + 90836
Regina