Billing99213

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Sunflower66

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Hi,

I was recently asked to bill in office fluoroscopy procedure codes along with a 99213 code. No other practice I have worked at billed 99213 along with ESI or MBB code.
Is this allowed?
I can understand if a patient needs a medication refill on the same day as the procedure but for those who do not need any additional workup, this just makes no sense to me.
Any advice appreciated. Thanks!
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fraud and whomever asked you knows this
 
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Great, thank you for the clarification. I will have to inform her of this.
 
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Fraud.. pretty obvious fraud.
 
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Haha.
Why not a 99215?
 
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a letter from a big insurance carrier today....

Reimbursement policy update: Implementation delay for evaluation and management codes
billed with modifier 25 and minor procedures
Dear <PROV_NM>,
We recently sent a letter informing you about an update we planned to make regarding reimbursement for
claims submitted with evaluation and management (E&M) Current Procedural Terminology (CPT® ) codes
99212, 99213, 99214, and 99215 and modifier 25 when a minor procedure is billed.
We are currently reevaluating this reimbursement policy change, which will delay implementation.
What this means
The Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same
Physician on the Same Day of the Procedure or Other Service reimbursement policy update will not go into
effect on August 13, 2022, as originally scheduled.
We will communicate a new implementation date and details after our internal evaluation is complete.
Thank you for the care you provide to our customers
 
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Sunflower66 said:
Hi,

I was recently asked to bill in office fluoroscopy procedure codes along with a 99213 code. No other practice I have worked at billed 99213 along with ESI or MBB code.
Is this allowed?
I can understand if a patient needs a medication refill on the same day as the procedure but for those who do not need any additional workup, this just makes no sense to me.
Any advice appreciated. Thanks!
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i've seen certain IPAs allow them . but not medicare or ppo
 
nvrsumr said:
fraud and whomever asked you knows this
Click to expand...

What if you do provide a separately billable E/M service?

The threshold for a 99213 is pretty low regarding medical decision-making and complexity. What if I review a patient's PT program, provide feedback on exercises, and clinically correlate the epidurogram with the pre-procedural MRI findings? Should I just "give that away?"
 
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The only times I try to use -25 is if I do a same day procedure for a consult, or if a patient's prescription comes due on the same day as their procedure. I try to keep med refills separate from procedures, but if they happen to correspond, I feel that I should definitely be able to bill for the separate medical decision making of refilling their Butrans and Lyrica.

Even still, -25s often get denied, or they only pay for one but not the other.
 
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drusso said:
What if you do provide a separately billable E/M service?

The threshold for a 99213 is pretty low regarding medical decision-making and complexity. What if I review a patient's PT program, provide feedback on exercises, and clinically correlate the epidurogram with the pre-procedural MRI findings? Should I just "give that away?"
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are you sure that is a separate body part?

sounds like that is all about the back, and using the epidurogram to discuss back symptoms seems very tenuous.


i use it when there is a completely different body part. case in point, today discussing treatment for the patients right rotator cuff injury before a lumbar epidural for lumbar radiculopathy.
 
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Ducttape said:
are you sure that is a separate body part?

sounds like that is all about the back, and using the epidurogram to discuss back symptoms seems very tenuous.


i use it when there is a completely different body part. case in point, today discussing treatment for the patients right rotator cuff injury before a lumbar epidural for lumbar radiculopathy.
Click to expand...

I follow the kinetic chain in my discussion...back, pelvis, hip, knee, ankle, foot...it's all connected.
 
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drusso said:
I follow the kinetic chain in my discussion...back, pelvis, hip, knee, ankle, foot...it's all connected.
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Unfortunately insurance doesn’t pay to be a good doctor.

It pays to do three focused visits on 3 different issues instead of one thorough visit.
 
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bedrock said:
Unfortunately insurance doesn’t pay to be a good doctor.

It pays to do three focused visits on 3 different issues instead of one thorough visit.
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1659715426847.png


"An established patient comes in for a repeat epidural for chronic radicular pain. The patient asked the physician about his "hip" pain from walking. Physical examination shows tenderness over the right lateral trochanter. The patient is counseled about altered gait mechanics and compensatory myofascial pain in the setting of chronic spinal disorders. The patient is shown exercises for strengthening lateral hip stabilizers. Low complexity medical decision-making. The modifer 25 with a 99213 used."
 
drusso said:
View attachment 358068

"An established patient comes in for a repeat epidural for chronic radicular pain. The patient asked the physician about his "hip" pain from walking. Physical examination shows tenderness over the right lateral trochanter. The patient is counseled about altered gait mechanics and compensatory myofascial pain in the setting of chronic spinal disorders. The patient is shown exercises for strengthening lateral hip stabilizers. Low complexity medical decision-making. The modifer 25 with a 99213 used."
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your example documents GT bursitis, which is different body part from the lumbar radiculopathy.

that makes sense to me.

talking about back exercises and stretches for back pain and doing an epidural for back pain radiating to the legs does not make sense as separate entities.
 
Nothing against the OP but this sounds like some chiro/pi set up where the office manager is telling the doc what to do in which case you can bill the 99213 as auto insurance will likely pay the code.
 
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Ducttape said:
your example documents GT bursitis, which is different body part from the lumbar radiculopathy.

that makes sense to me.

talking about back exercises and stretches for back pain and doing an epidural for back pain radiating to the legs does not make sense as separate entities.
Click to expand...

Who's side are you on?
 
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Ducttape said:
your example documents GT bursitis, which is different body part from the lumbar radiculopathy.

that makes sense to me.

talking about back exercises and stretches for back pain and doing an epidural for back pain radiating to the legs does not make sense as separate entities.
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Where does it say it has to be a different body part? Looks like just a different problem/diagnosis to me. For example, ddd and facet oa are different.
 
Wait...Do yall bill office codes on procedure visits bc you spoke to the pt about their knee pain while doing an ESI?

WTF?
 
I bill if I'm doing an EMG. I bill if they're there for office visit for spine but also want knee inj etc
 
I use -25 modifier all the time if I do joint injections or TPIs in office. Usually bill a 99213 or 99214 and add -25. Everyone is still doing this correct?
 
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clubdeac said:
I use -25 modifier all the time if I do joint injections or TPIs in office. Usually bill a 99213 or 99214 and add -25. Everyone is still doing this correct?
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Do you get paid for this?

I used to, but I always get paid for one or the other. Now I will do the 99213/99214 then come back different day for injection only.
 
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Years ago I used to mod 25 and 99213 if I ordered knee xray or whatever while talking to patient during procedure. Had a few insurance companies pay the 99213 and not the scs trial or rf codes so stopped quick after appeals didn’t work.
 
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I do injections separate days from om ov
 
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nvrsumr said:
Years ago I used to mod 25 and 99213 if I ordered knee xray or whatever while talking to patient during procedure. Had a few insurance companies pay the 99213 and not the scs trial or rf codes so stopped quick after appeals didn’t work.
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Wow. Good info.

Yep patients just need to come for extra visits.
 
So, if a patient had 6 months of relief from ESI, pain returns …u re-evaluating them for their back pain and leg pain, confirming with them that it’s in the same location, reviewing the previous MRI findings , confirming no contraindications (anticoagulants etc), that is not enough to justify a 99213-25, if u did the ESI the same day as the re-eval?
 
painfree23 said:
So, if a patient had 6 months of relief from ESI, pain returns …u re-evaluating them for their back pain and leg pain, confirming with them that it’s in the same location, reviewing the previous MRI findings , confirming no contraindications (anticoagulants etc), that is not enough to justify a 99213-25, if u did the ESI the same day as the re-eval?
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You bring them back in 6 months for re-eval and order ESI to get the precert.
If they call for ESI and you can get the precert done without an OV, then just do the ESI.
 
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clubdeac said:
I use -25 modifier all the time if I do joint injections or TPIs in office. Usually bill a 99213 or 99214 and add -25. Everyone is still doing this correct?
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Trigger point injections, simple knee and shoulder injections I will bill mod-25 and specifically code to Knee Pain, Shoulder Pain, Myofascial Pain for the procedure as I was instructed this would be the most likely way to get paid for both. I also report a separate ICD 10 code for the office visit. I’m willing to do this when it’s too much trouble to have the patient come back for a separate visit and I just want to fix the problem.
 
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Agast said:
Trigger point injections, simple knee and shoulder injections I will bill mod-25 and specifically code to Knee Pain, Shoulder Pain, Myofascial Pain for the procedure as I was instructed this would be the most likely way to get paid for both. I also report a separate ICD 10 code for the office visit. I’m willing to do this when it’s too much trouble to have the patient come back for a separate visit and I just want to fix the problem.
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Same
 
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Ferrismonk said:
Do you get paid for this?

I used to, but I always get paid for one or the other. Now I will do the 99213/99214 then come back different day for injection only.
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I assumed I was. We are supposedly paid on wRVUs billed and not what the insurance pays, so they tell us.
 
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I RARELY bil -25 on fluoro cases at the hosp; but OFTEN bill -25 E and M with in office procedures (TPI, USGI, Botox, OMT, Acup)
 
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Insurances/CMS continue to impose nonsense billing rules for purely profit motive and/or to contracture of healthcare costs . Weak specialties , like ours comply . Insurance companies (blue cross) are the banks for CMS, , esp during Covid HSS grant handouts . There is an unholy alliance between big insurance and big government health policy. Inflation is kicking in. There will be a braking point ..

Unless something changes most private practice is toast . There is no negotiating power due to the ACA ,and ‘unjust’ site payment differentials(drusso doctrine 😂) We are lucky to have practiced thus far in an ending Golden Age …
 
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I bill 99213 plus a procedure in this scenario in my private office.

Patient has insurance that does not require authorization. They have already had two mbb’s. We discussed the result
Of the mbb’s in the exam room. We decide to proceed with rfa that same day. I do not bill modifier 25 in this scenario. This same scenario and billing is done each time I decide to do a procedure on someone that doesn’t need auth. I am billing the office visit to account for the medical decision making.

I use modifier 25 if I am also refilling medications, reviewing studies, etc if it is unrelated to the procedure.
 
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25 modifier is really otherwise an office visit but i decide to do same day procedure - mostly joints and tpi but often esi too on initial consult. I only do this for medicare. Anything beyond tpi for private i have them come back - such as fluoro guided joint injection
 
Ducttape said:
Truth, Justice and a Better Tomorrow.

(its not Truth, Justice and the American Way any more)
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Truth, justice and the American way. Sounded so legit coming Christopher reeves
 
BobBarker said:
I bill 99213 plus a procedure in this scenario in my private office.

Patient has insurance that does not require authorization. They have already had two mbb’s. We discussed the result
Of the mbb’s in the exam room. We decide to proceed with rfa that same day. I do not bill modifier 25 in this scenario. This same scenario and billing is done each time I decide to do a procedure on someone that doesn’t need auth. I am billing the office visit to account for the medical decision making.

I use modifier 25 if I am also refilling medications, reviewing studies, etc if it is unrelated to the procedure.
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Glad that works for you. In my world, I'd get paid the 99213 and be denied the RF payment.
 
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painfree23 said:
So, if a patient had 6 months of relief from ESI, pain returns …u re-evaluating them for their back pain and leg pain, confirming with them that it’s in the same location, reviewing the previous MRI findings , confirming no contraindications (anticoagulants etc), that is not enough to justify a 99213-25, if u did the ESI the same day as the re-eval?
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that seems all part and parcel to the injection itself.

the -25 modifier is when the procedure is minor. so im happy to talk about other issues during TPIs, but if it is any procedure more extensive, the patient has to come back at a different time to discuss.


i was told to make sure it was a separate body site from the system's Compliance, but looking at this website, apparently it can be the same body site - if the pain is much worse or changed...

www.aapc.com

Are You Using Modifier 25 Correctly?

Don't lose revenue when a service or procedure gets more involved. Here's what you need to know about modifier 25 and reporting extra work.
www.aapc.com www.aapc.com
 
so, like most things in billing, -25 modifier purposely ambiguous. this way, coverage can be denied without any legitimate rationale. they scare you into underbilling. dont fall for it. definitely bill the -25 modifier, and also bill a 9921x E/m code the same day as an injection. however, there is a lot nuance here. both services MAY get paid depending on the particular insurance product. some may not.

pro tip for clubdeac and others who are hospital employed. the billing software will calculate RVUs based on what you bill, not based on what is collected on the other end. bill for EVERYTHING. let the billing department chase down what gets paid and what doesnt. you should hear if there is a big disconnect of if one gets paid and the other doesnt, but do not leave those RVUs on the table. clearly this doesnt work in a private practice scenario where actual money is the currency
 
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