Dealing with Modifier -25 denials for office visits and skin testing

Dealing with Modifier -25 denials for office visits and skin testing

The Advocacy Council regularly receives queries from members on how to correctly code specific scenarios. Recently we received a request for coding an office visit the same day as skin testing.

Many third-party payers insist that skin tests are a part of an office visit, but this is not the case, and these denials should be appealed.

Modifier -25: this Modifier is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional.

Modifier -25 should be appended to the E/M service, indicating a significant, separately identifiable service was performed at the time of the E/M service.

A significant, separately, identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.

In a separate note, document the testing, the results, the patient’s therapeutic options, and your discussion of the risks and benefits of each option. Based on the shared decision-making, develop an action plan. In this note, avoid reference to the E/M service, if possible.

In other words, if you are able to bill each of these services independently, you are using the modifier -25 correctly. You should appeal denials you believe are unwarranted.

Through dealings with one of the major insurance companies, the Advocacy Council learned that the insurer relies on a computer algorithm to flag modifier -25 claims. Those claims are then sent for review by a nurse/certified coder who looks at the claim and considers it in light of the physician’s history of denials and appeals (but without access to medical records).

If the physician has a significant number of denials and a low appeal rate, it weighs against approval of the claim since it creates an inference that the physician is billing inappropriately. On the other hand, if the physician has appealed a high percentage of denials, and a high percentage were overturned and paid, it is likely the claim will be approved for payment. According to this insurer, about 60% of claims flagged by the algorithm end up being paid upon review by nurse/coders.

Allergists should make sure their medical records support use of modifier -25 and should appeal denials they believe are unwarranted. Not only is it a chance to get reimbursed, but failure to do so could count against you in future denials and in having your claims flagged for review.

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