New Medicare stand takes you away from modifier 25.
In case your family physician regularly orders an EKG as component of patients' annual visits, you should certainly double check your modifier reporting prior to filing claims. Medicare now needs a modifier on claims reporting EKGs as component of a patient's annual wellness visit (AWV) for dates of service. Read on to know how to submit clean claims in such scenarios.
Scenario: You submit a claim to Medicare using G0438 (Annual wellness visit; includes a personalized prevention plan of service [PPS], initial visit) as well as EKG code 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). Medicare pays for G0438, but rejects the EKG on the basis that your claim either includes an invalid modifier or doesn't have a modifier.
In case Medicare won't accept modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on these given claims, what are the acceptable options? Read on for guidance from real-world coders on how to submit clean claims for EKG during an AWV.
Move to Modifier 59
As Medicare no longer accepts modifier 25 for these given situations, your best option is modifier 59 (Distinct procedural services).
When you will run the scenario through your code checker for CCI edits after receiving denials, it will indicate that -59 is the only acceptable modifier for code 93000.
Difference: One way to help come to a decision whether to append modifier 25 or modifier 59 to your claim is to take a more detailed look at the service your physician offers. You should only append modifier 25 to an E/M service code. When the physician carries out an EKG together with an annual wellness visit, it is the EKG, not the E/M code that is potentially being bundled. As you are trying to independently report an EKG rather than an E/M code, you can't report modifier 25; you have to use modifier 59 as a substitute if you wish to submit clean claims.
Confirm Diagnosis and Referrals
Even though you should always code based on the physician's documentation, payers have policies stating which diagnoses bear medical necessity for procedures. The two diagnoses they use most frequently for EKG as component of an AWV are 272.4 (Other and unspecified hyperlipidemia) and 401.9 (Unspecified essential hypertension).
Payers from time to time need a referring physician's name and NPI (National Provider Identifier) prior to approving charges for an EKG. If you want to submit clean claims, then you should always check guidelines for the payer in question to authenticate whether the patient requires a referring physician prior to having the EKG.
Click here to submit clean claims and read the whole
article for more accurate and profitable expert coding advice:
http://www.supercoder.com/articles/articles-alerts/fca/annual-visits-ensure-correct-modifier-reporting-for-ekg-with-annual-visit-or-face-denials-107760/
In case your family physician regularly orders an EKG as component of patients' annual visits, you should certainly double check your modifier reporting prior to filing claims. Medicare now needs a modifier on claims reporting EKGs as component of a patient's annual wellness visit (AWV) for dates of service. Read on to know how to submit clean claims in such scenarios.
Scenario: You submit a claim to Medicare using G0438 (Annual wellness visit; includes a personalized prevention plan of service [PPS], initial visit) as well as EKG code 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). Medicare pays for G0438, but rejects the EKG on the basis that your claim either includes an invalid modifier or doesn't have a modifier.
In case Medicare won't accept modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on these given claims, what are the acceptable options? Read on for guidance from real-world coders on how to submit clean claims for EKG during an AWV.
Move to Modifier 59
As Medicare no longer accepts modifier 25 for these given situations, your best option is modifier 59 (Distinct procedural services).
When you will run the scenario through your code checker for CCI edits after receiving denials, it will indicate that -59 is the only acceptable modifier for code 93000.
Difference: One way to help come to a decision whether to append modifier 25 or modifier 59 to your claim is to take a more detailed look at the service your physician offers. You should only append modifier 25 to an E/M service code. When the physician carries out an EKG together with an annual wellness visit, it is the EKG, not the E/M code that is potentially being bundled. As you are trying to independently report an EKG rather than an E/M code, you can't report modifier 25; you have to use modifier 59 as a substitute if you wish to submit clean claims.
Confirm Diagnosis and Referrals
Even though you should always code based on the physician's documentation, payers have policies stating which diagnoses bear medical necessity for procedures. The two diagnoses they use most frequently for EKG as component of an AWV are 272.4 (Other and unspecified hyperlipidemia) and 401.9 (Unspecified essential hypertension).
Payers from time to time need a referring physician's name and NPI (National Provider Identifier) prior to approving charges for an EKG. If you want to submit clean claims, then you should always check guidelines for the payer in question to authenticate whether the patient requires a referring physician prior to having the EKG.
Click here to submit clean claims and read the whole
article for more accurate and profitable expert coding advice:
http://www.supercoder.com/articles/articles-alerts/fca/annual-visits-ensure-correct-modifier-reporting-for-ekg-with-annual-visit-or-face-denials-107760/
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