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Apr 7th, 2016 - dianawalp 1 

Lacrimal plug and E/M code billed - some paid some denied

Hello and thank you for providing this forum for billers/coders like myself.
I wish to remark upon an Accounts Receivables “trend” specifically pertaining to Lacrimal plug(s) insertion (68761 E2, E4) billed with E/M code 99214 – to the SAME insurance carrier, as well as ask for your opinion and advice about the following:

Claim Example A:
Primary dx: H16.143 (Punctate keratitis bilat)
2y dx: H04.123 (Dry eye syndrome bilat lacrimal glands)

Billed: 99214 (25) Diagnosis pointer 1,2
68761 E2 Diagnosis pointer 1,2
68761 51 E4 Diagnosis pointer 1,2
Insurance pays for both plugs AND PAYS the E/M code 99214

Claim Example B:
Primary dx: H16.223 (Keratoconjunctivitis sicca not specified as Sjogren’s bila)

Billed: 99214 (25) Diagnosis pointer 1
68761 E2 Diagnosis pointer 1,2
68761 51 E4 Diagnosis pointer 1,2
Insurance pays for both plugs AND DENIES the E/M code 99214

This is the pattern, and payment has become “predictable”. What confounds me and our AR department is WHY pay for the E/M code on one and not the other? Yes, the ICD-10 not the exact same- but still in same category, no?
Don’t mean to sound glib, but I wanted to present this puzzle to a fresh pair of eyes…
I sincerely hope that you would be so kind as to review the above and respond with your thoughts.
Thanking you in advance for sharing your erudition in order to accurately address this particularly “gray” area of insurance coding.

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Apr 8th, 2016 - LBAROGIANIS 250 

re: Lacrimal plug and E/M code billed - some paid some denied

My guess would be on the second example is that you only have one diag code listed,but you do have it pointing at 1,2 on procedure. If you are using modifier 25 then you are stating there is a separate reason for needing to see physician. If you only have one diag code then you only have one reason to see the physician. Hence, insurance companies will pay for a procedure that relates to the diag code. This is my guess why they paid for procedure and not E/M visit.

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Apr 8th, 2016 - dianawalp 1 

re: Lacrimal plug and E/M code billed - some paid some denied

Thanks so very much for your swift response.

Just when you thought it was safe to go back in the water...
Here's the SAME situation as indicated previously, only on a completely different patient:

Diagnosis 1 ICD-10 H16.143 (Punctate Keratitis bilat)
Diagnosis 2 ICD-10 H04.123 (Dry Eye Syndrome of bilat lacrimal glands)

Procedure 1 CPT® 99214 (25) Diagnosis Pointer: 1,2
Procedure 2 CPT® 68761 (E2) Diagnosis Pointer: 1,2
Procedure 3 CPT® 68761 (E4) (51) Diagnosis Pointer: 1,2

The SAME insurance paid for both lacrimal plugs (happy with that), but...
DENIED the E/M code, indicating:
Line 1- M144- Pre-/post-operative care payment is included in the allowance for the surgery/procedure".

Odd, when you think about how they paid the E/M code on the other one.
What can you surmise about that?
Here's another idea: What if I was to resubmit the claim, but as corrected, with appended modifier ( 24 ) on the E/M code? After all, modifier 24 does mean additional service appended to an evaluation and management service (never to a procedure) to indicate that an unrelated E&M service was provided by the same physician during a postoperative period.

I am asking two questions here: 1) what happened with the most recent claim denying the E/M code with the lacrimal plugs when that same insurance paid before for identical coding on a different patient?
2) Should I have used modifier (24) instead of (25)? Would that have made a difference?
I am at a loss how to explain this... Please advise. And, Thank You Again Very Much For Your Previous Reply (which was truly an Aha! moment for me- it made perfect sense, albeit short-lived). Looking forward to your response.

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