UHC and Aetna denying office visits as "part of other procedure"

[preacher35]

I'm new here (but glad I found this forum) and I was wondering if any of you have come across this problem that we have been having lately.  A perfect example: we billed UHC for a 99214 (ext office visit), 93000 (EKG) & 96372 (administer injection).  UHC denied the office visit stating that is "NOT  A SEPARATELY REIMBURSABLE SERVICE OR SUPPLY).  Upon calling UHC, I was told that the office visit code is a part of the 96372 (administer injection)!  Aetna did something similar.  A patient's policy was billed for a 99212 (brief office visit) and a 16020 (dressing without anesthesia).  Aetna denied the 99212 stating that it was integral to the 16020!  We didn't see this tactic last year but it looks like it's becoming a more common trend.  Do any of you have a strategy for preventing this type of denial?  Thank you in advance!

[Steve Verno]

Yes, you fight back and never give up
Both aetna and united are wrong
use your NCCI edits to fight back

Now, if your doctor is contracted,then fighting back may not be possible

[preacher35]

Thanks for the reply, Steve... and yes, my doc is contracted with both companies.  Of course, both companies have expressed the fact that I can appeal, but as we already know, my only basis for an appeal would be to argue that their "criteria" is invalid... and nobody EVER wins those appeals.  If anybody else has a suggestion, I would appreciate it.

[Steve Verno]

The problem is, the contract may have language that your doctor agreed to the insurance companies coding policies, even though they may contradict industry coding standards.  Hence, no appeal. 

[BeachBiller]

If your patient was there for seperatly identifiable reasons you can bill a modifier 25 on your 99214 & they will pay all codes..

Ex: if your pt was there for chest pain, so you did the EKG, but they were also there for an allergic reaction so you did the 96372 then you could bill the 99214.

however, if your pt was there for chest pain and the 96372 was related to the chest pain, then the ins is correct and your ofc visit is included in the injectin.

[Steve Verno]

Im sorry, I disgree with two statements.

Using modifier 25 does not gurantee payment.  Modifier 25 is one of the most abused modifiers and is under the watch of the OIG.  Modifier 25 simply records that the E/M is a significant and separate visit but in some cases this may not be so. 

As a patient, I have two doctors billing me for high level E/M visits, yet the purpose of both visits were not for an office visit.  One visit was for a diagnostic test,  the other was for surgery.  In addition, the documentation doesnt support the level of visit being billed.  When challenged with CPT and CMS Documentation guidelines, the office managers both responded that they can bill the E/M because they used modifier 25.  Both doctors are under investigation for fraud. 

an office visit is NEVER included in an injection. 
If the purpose of a visit is an injection, you do not bill the office visit because it cannot be justified.

Just because an insurance company denies, doesnt mean they are right.
There are also extenuating circumstances such as insurance contracts, coding policies that a doctor agreed to accept.

Here we have the main reason why forums have limitations on what we can present as answers.  We dont know what was documented and we dont have access to the chart, the original claim, or the EOB.  Therefore we cannot say you can bill AAAAA, BBBBB, CCCCC or DDDDD.  We dont know if the codes being billed are correct in the first place.   

[BellaVega]

If your patient was there for seperatly identifiable reasons you can bill a modifier 25 on your 99214 & they will pay all codes..

Ex: if your pt was there for chest pain, so you did the EKG, but they were also there for an allergic reaction so you did the 96372 then you could bill the 99214.

however, if your pt was there for chest pain and the 96372 was related to the chest pain, then the ins is correct and your ofc visit is included in the injectin.

This is what I was thinking. If your patient came to the office for a certain service or test or vaccine, then the visit is part of the service, test or vaccine. But with this thinking, the only typical visits that you could charge for would be a check-up or a sick visit.