Outpatient Facility Coding Alert - 2020 Issue 8
Reader Questions: End This EOL Modifier Mistake
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Article Overview
This article explains a payer denial tied to a claim that included an office/outpatient evaluation and management service and advance care planning services. It is written for coders and billing staff who work with E/M reporting, CPT add-on services, and modifier application in the context of end-of-life counseling and advance directive discussions. The discussion focuses on the coding concepts involved, the general source of the issue, and the relevant CPT guidance discussed by the author.
Why This Topic Matters
Claims for advance care planning performed during an E/M encounter are commonly reviewed for correct modifier assignment and bundling. Understanding how these services are discussed in CPT and how payers may react to modifier combinations can help reduce denials and resubmissions.
Article Sections
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Question
A reader describes a denial on a claim involving an established patient E/M visit and advance care planning during an end-of-life discussion.
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Answer
The response discusses the likely source of the denial, references CPT Appendix A guidance, and explains the general modifier-related issue at a high level.
What You Will Learn
- How this type of denial is framed in a payer response
- The general relationship between evaluation and management services and advance care planning reporting
- Why CPT Appendix A is relevant to the discussion
- How add-on services and modifier assignment are addressed in the article
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle staff
- Compliance staff
- Physician practices
- Office managers
Codes Discussed
Modifiers Discussed
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