How to counteract bundling of E & M with spirometry codes

Lately, I've found that when I code an E & M visit (say 99213) at the same time as spirometry (94010 and/or 94375), the HMO pays for a spirometry code and denies the office visit, saying that "it is included in the primary procedure" or some words like that. When I called, I said that it is common for me to see a patient with asthma or asthmatic bronchitis, evaluate them, and then decide to perform spirometry to aid in diagnosis and treatment--ie, there are two separate procedures going on. They vaguely suggested that a modifier be used, without telling me which one. I've added -59 to the spirometry codes, but they denied it. Is -25 an appropriate modifier to use? If not, how SHOULD I be billing this in order to be paid for both the visit and the procedure?

How to counteract bundling of E/M with sprirometry codes

You could try a 25 modifier on the E/M--have you done that? It's not required according to coding rules, but it will sometimes by pass the edit.

Only do it on this insurance company, and be especially careful not to do it for Medicare. Medicare warns us about using modifier 25 when it is not needed, because it makes them think that we don't know the correct use of it.

There are many articles on Codapedia that discuss this modifier.

There is also advocacy, if this is a carrier that is important to you. Call the provider rep/medical director/your contracting contact and tell them about the problems you are having. Explain that while you want to continue participating with them, you can't afford the added cost and complexity of dealing with a payer that doesn't follow CPT rules.

Are you capitated? It's an HMO

One of our local HMO's bundles EKG and spirometry into our capitation payments. It OBVIOUSLY makes no sense, but they do it anyways. Their argument is that the supply cost is minimal and the work of interpretation is an integral part of primary care medicine. The IPA that controls the fee schedule is physician-governed so I can only be mad at my colleagues, not at the insurance company.

E&M and spirometry

If the E&M is the significant separate service and is performed on the same day as either of the procedures defined by CPT code 94010 or 94375 the modifier 25 is appended to the E&M service. If the intent of the visit is to perform the procedure defined by either of these two services then the E&M is not separately reportable on the same day unless another problem/diagnosis was evaluated and managed.
Medicare CCI bundles these two services as inclusive to each other.

Mary LeGrand, RN,MA, CCS-P,CPC.

Medicare and spirometry

Does medicare always bundle spirometry (CPT 94010) with the E&M code for the day? What if we use separate ICD9 codes for both the spirometry and the office visit? Or is the only way to get paid for both by medicare is to have the patient come back on another day for the procedure?