Forum - Questions & Answers

Feb 10th, 2016 - TerryC 39 

modifier help Please

We have a new computer system. We are running into a problem I haven't had before. A patient comes in for either a physical or AHA (G4038/G0439). If they have other problems we bill a E/M (99213)code also. Then if they have eg: 17000,20600,17110 etc. done I usually bill as follows.
99396/G0439
17000-59
99213-25
Insurances are saying the 99396/G0439 are bundled. Is there a modifier I can put on the 99396/G0439? I haven't done this in the past. I don't think the 59 would work on the 99396/G0439 also I don't think I can use the 25 twice. Any help appreciated. Thanks

Feb 10th, 2016 - codinqueen 57 

re: modifier help Please

I think your problem is that you are trying to bill an INITIAL comprehensive preventative E&M code with a SUBSEQUENT Annual wellness/preventative exam. I don't have access to a HCPCS book, so I cant read any other info published there regarding if you can or cannot bill the HCPCS code and the CPT┬« code BOTH. They seem to be redundant, but differ only by initial and subsequent clarifier...in other words it seems both codes say the same thing except one is INITIAL and the other is a SUBSEQUENT visit. I think you need to decide if your pt is having an INITIAL visit or a SUBSEQUENT visit and choose one of the 2 codes listed. I am not sure if you can bill this once in CPT® and once in HCPCS. I am a facility OPS coder, not a coder for a physician office, so I hope somebody else chimes in with an answer for you.

Feb 10th, 2016 - Codapedia Editor 1,399 

re: modifier help Please

I think it is unusual to bill for a wellness visit, a CPT® preventive medicine service and an office visit on the same day.

If you do, you have to charge the patient their portion of the non-covered service.

Feb 10th, 2016 - TerryC 39 

re: modifier help Please

Sorry to both replies above. I didn't mean to say we bill the 99396,G0439,99213 and 17000. I was just trying to give a couple of examples. What I meant is if we billed a 99396,99213,17000. OR a G0439,99213,17000. I don't know if a modifier 25 could be used on both the 99396 and 99213? Thanks

Feb 10th, 2016 - Codapedia Editor 1,399 

re: modifier help Please

Sorry, now I see.

I hate to answer this in this way, but I think it will depend on your payers. Some may require it on both in order to get the 17000 paid (although I think correct coding would put it on only the 99213. I think) Your software may give you a hard time with edits....

Feb 10th, 2016 - codinqueen 57 

re: modifier help Please

Yes, I agree. Software edits can be a pain and are not always valid. The CPT® book says you can bill Preventive Wellness visits with E/M codes in the right circumstances. I am not sure if modifiers would help you. You might need to link the dx for each CPT® code to the dx that fits. Sorry I cant be more help.

Feb 10th, 2016 - TerryC 39 

re: modifier help Please

Thank you both, I guess I will have them try on both and see what happens.

Feb 10th, 2016 - codinqueen 57 

re: modifier help Please

I suggest you discuss with the Dr if he would like to have the pt reschedule for the other problem because the time allotted for the preventive care visit doesn't (or shouldn't) include time for the problem visit. When the pts make the appt for the health assessment/preventive care exam, they should be told if they have a problem requiring more time you would be happy to make them another appt for that special problem on a different day. You may still have some pts who won't care, and will expect to have their other problem dealt with on the same date of service as the preventive care, but you might be able to discourage some of them from taking advantage of the system. Maybe preventive exams should be scheduled on a certain day of the week and you & the DR could explain this when the pt makes the appt and when the pt shows up for the appt. Some pts will complain because it may be difficult to get transportation to the office for 2 different days, but this would allow the Dr to be thorough with EACH visit and be paid correctly without requiring the use of modifiers. Just a suggestion. Some pts will take a mile if your office gives them an inch if you know what I mean. I know my DR will not deal with any of my current problems when I make an annual health exam visit, he has me make an appt to come back another day so he can focus on my problem.



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2023 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association