December 21st, 2016
We are continually getting denials when we bill office visit E/M code 99213-25 along with a CMT on dates that we do re-exams. When we appeal they always uphold their original decision even though we provide clear evidence that all of the bullets for the 99213 have been satisfied and that this is a re-exam after a months of care. Any advice?
Page 323 of your 2017 ChiroCode DeskBook covers examples of situations where the 25 modifier might be applied to evaluation and management codes because the service is significant and separately identifiable from the CMT. Here are some examples:
- Periodic re-evaluation (see the CCGPP algorithms in Chapter 4.5 — Treatment Plans and Outcomes Assessments for more guidance)
- A new condition or injury
- Exacerbation, aggravation, or re-injury
- Return after lapse in care
- Counseling (using the Time override)
- Release/discharge from active care
The official guidance is: "Additional Evaluation and Management services... may be reported separately using modifier 25 if the patient’s condition requires a significant, separately identifiable E/M service above and beyond the usual preservice and postservice work associated with the procedure." Consider appealing the decision and referencing the above quote from the 2017 CPT book.