Coding, Classification and Reimbursement

Coding EM levels in OP Setting- Insurance

  • 1.  Coding EM levels in OP Setting- Insurance

    Posted 10-19-2018 11:22
    We are seeing a huge increase in denials from our OP visits ( specifically ED/clinic office settings) stating that they will not accept 2 EM levels for a single episode of care. One of the EM levels is a facility level and the other is a Professional EM level that we have always done in the past. How are you all handling these types of denials ? The payers are asking for various modifiers be placed on these such as -25 and -27.  What is your experience with these ? Feel free to respond to this post here or email me at kseverson@masongeneral.com. I look forward to your input as it will be much appreciated !!

    Help !
    Kathy

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    Kathryn Severson
    Him Director
    Mason General Hospital
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  • 2.  RE: Coding EM levels in OP Setting- Insurance

    Posted 11 days ago
    It looks like you didn't get any feedback here - if you have any direct email contact regarding this I'd be interested in what you learned. Feel free to email me at mburke@ftmc.com. I would like to compare "notes" perhaps about some similar experiences.  Thank you

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    Mona Burke, RHIA, FAHIMA

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  • 3.  RE: Coding EM levels in OP Setting- Insurance

    Posted 11 days ago
    Hello,


    Modifer 27 was created for hospital outpatient departments only. It would not be appropriate for use by physician practices.

    I am reading an article from Novitas and it states "hospitals may append modifer 27 to the second and subsequent EM code to indicate that the EM service is a separate and distinct EM encounter from the service previously provided that same day in the same or different hospital setting"

    I am curious to know what other information you will be or have been provided with.







  • 4.  RE: Coding EM levels in OP Setting- Insurance

    Posted 11 days ago
    Is this for commercial payers. 
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    Sent from Gmail Mobile Samantha





  • 5.  RE: Coding EM levels in OP Setting- Insurance

    Posted 11 days ago
    I work at a FQHC and we use modifier 25 and it processes the claim with no problems. You have to make sure that there is documentation showing there are 2 separate E/M encounters. Hope this helps.

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    Steve Oehmen
    Outpatient Coder & Biller
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