Whether you’re new at coding or an experienced coder, you face a great risk of falling into certain evaluation and management (E/M) coding traps – which can cost your urology practice its reimbursement. You need to stay current on the most prevalent causes of denials when billing for E/M services, or face one denial after another.
Keeping up with the rules for each E/M level of service and the required documentation to ensure accurate billing can be difficult, says Michael A. Ferragamo, Jr., MD in the ProfEdOnDemand audioconference “A Last Look at E/M Coding for Urologists.” And even seasoned coders face challenges breaking down all the complex clinical scenarios that can cause confusion about which level of service you should select.
Avoid these three most common E/M-related claims denials:
1. Post-Surgical E/M Services
Problem: Urology coders will certainly see denials from time to time due to global surgery billing requirements. This can happen if you submit a claim for services the urologist provided to the same patient on the same day as (or within) the post-op period of a procedure, according to a tutorial by Palmetto GBA. These services are often bundled into the global surgery package and not paid separately.
Solution: Before you submit a claim for post-surgical E/M services, you must verify the post-op period, Palmetto GBA advised. Check the surgery date and number of follow-up days associated with the surgical procedure. Use CPT modifiers 24 and 25 as necessary.
Modifier 24 is appropriate for indicating when an E/M service that falls within the global period is unrelated to the surgery. Or append modifier 25 when the E/M service (performed on the same day as a minor surgery) is significant and separately identifiable from the usual work associated with the surgery.
What’s more: Correct Coding Initiative (CCI) edits are another common source of bundling-related denials, noted the California Academy of Family Physicians (CAFP) in a recent report. Make sure you’re paying attention to Medicare’s quarterly edits to know which pairs of codes you should not bill together because they are mutually exclusive or because one is more comprehensive than the other.
2. ‘New’ Patient Denials
Another common E/M-related denial involves billing services for new patients. Denials typically occur because you didn’t meet the new patient qualifications or failed to include specific information, stated a tutorial by Novitas Solutions. A new patient is one who has not received any professional services from the urologist or the urology group practice within the previous three years.
Essential: To bill an E/M service for a new patient, you must verify that the patient is new to your group practice for the provider specialty billed – urology, Novitas noted. Ensure that the physicians and non-physician practitioners (NPPs) are trained as a different specialty or sub-specialty than the providers within your group practice who have previously treated the patient. Also, make sure you review the patient’s medical records to verify the specialties of previously billed E/M services within the group practice.
If you’re appealing a denial, you must submit documentation for the specialty and sub-specialty of both the provider in question and any NPP who’s seen the same patient within the group practice, Novitas advised. Details to include are the providers’ names, National Provider Identifiers (NPIs), specialty and sub-specialty (if applicable), and the specialty code (if applicable).
3. Red-Flag Modifiers
Pay attention: The two most common modifiers to cause denials are modifiers 25 and 59, according to CAFP. When you use modifiers incorrectly, payers will deny the services to which you’ve appended the modifiers.
Modifier 25 indicates a significant, separately identifiable E/M service provided on the same day as another procedure or service, CAFP noted. But modifier 59 indicates that a procedure or service is distinct from another procedure or service either because it:
- Occurred during a separate encounter;
- Was performed on a separate organ/structure;
- Was performed by a different provider; and/or
- Does not overlap usual components of the main service.
Watch out: Recently, providers have experienced automatic denials from some Blue Cross Blue Shield plans for claims containing modifiers 25 and 59, according to a blog posting by Julie Lenhardt for the American Chiropractic Association. In some cases, providers received a letter stating they used the modifiers inappropriately, while in other cases the letters stated their utilization of the modifier is higher than average.
Also, there has been so much confusion over when to use modifier 59 that Medicare has established new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of modifier 59, the CAFP pointed out.
Takeaway: When you’re tackling tricky E/M level-of-service decisions, you need to know not only the basic components of an E/M code and how to correctly code the services, but also the factors that can lead to denials and audits, Ferragamo warns. After all, correctly coding and selecting the right level for E/M services can ensure that your urology practice is getting the reimbursement it deserves.
