Forum - Questions & Answers

Nov 4th, 2013 - kkbloom 3 

BCBS is not paying us for both the physical and the E/M code.

This is what I billed:
99396,
82274-QW,
90471,
90658,
36415,
99213-25 (Hypertension and Choleterol were discussed)

BCBS paid for everything but the 99396 which was for the physical and was the most expensive lined item. The code reason I was given was CO-97 which states the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjusdicated.

Do you know a different way I can bill this so I can get paid for our CPT® code 99396?

I contacted BCBS but they said even though I used a modifier that they had grouped both the 99213 and 99396 together. I have not had this problem before. I'm wondering if the 90471 code is throwing it off and if I need to add an additional modifier to this in order to get that lined item paid. Any and all help would be greatly appreciated.

Thanks!

Nov 5th, 2013 - rphelps 615  1 

re: BCBS is not paying us for both the physical and the E/M code.

What diagnosis code did you use. I get paid using V70.0

Nov 5th, 2013 -

re: BCBS is not paying us for both the physical and the E/M code.

For BCBS, We have to put modifier 25 on both the E/M and physical code.

Nov 5th, 2013 - kkbloom 3 

re: BCBS is not paying us for both the physical and the E/M code.

Well, that is something to try. Thank you for your feed back. I will send in a correct claim and see what happens with that.

Aug 4th, 2016 - zavalag 3 

re: BCBS is not paying us for both the physical and the E/M code.

hello, we are having the same problem. Is it appropriate coding to add two modifiers on a claim (EM and Prev visit)? We don't want to start using it to bypass edits and get paid if not appropriate. I just cant find anything in writing stating it was acceptable to use it twice. With all this hype of excess use of modifier 25 and OIG looking into it, I would prefer to have supporting documentation it was fine. Thank you.

Nov 5th, 2013 - kkbloom 3 

re: BCBS is not paying us for both the physical and the E/M code.

For the 99396 the diagnosis code is V70.0
For the 99213-25 the diagnosis codes were 401.1 and 272.0



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