Billing > Billing
Re: billing 99354
Michele:
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.
best biller:
empire plan denied 59 modifier, the provider is out of network
Michele:
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?
PMRNC:
--- 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?
--- End quote ---
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.
Michele:
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.
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