Question: Why do my Evaluation & Management (E&M) codes keep getting denied when I bill them in conjunction with spinal manipulation?
I have been receiving increasing inquiries regarding the denial of Evaluation and Management (E&M) codes 99201-99215 when billed with chiropractic manipulation.
I noted this trend first with Illinois Blue Cross and Blue Shield, which would automatically deny the E&M code as being inclusive to the services provided. More recently, in other states with plans such as Aetna, in addition to Blue Cross and Blue Shield, the same has continued. Interestingly, California Blue Shield, beyond stating it is inclusive to another service, is also indicating more specifically to a post-operative service, which is ludicrous.
Based on medical necessity and professional standards, a provider must perform an examination to determine the patient's condition and course of care. A provider should be paid for this evaluation separately (as do medical providers) unless the provider has a contract with the payer that the exam is inclusive to the payment of other services. (Note that some HMO / PPO plans have such provisions with their provider agreements.)
Your First Defense: Modifier 25
These denials generically state, "The service billed is included in another procedure billed the same day." Of course, this is the exact reason why modifier 25 is appended to the E&M code when billed with chiropractic treatment including chiropractic manipulative therapy (CMT) or physical medicine services. The 25 indicates there was a separate and distinct evaluation above and beyond the pre- and post-service evaluation associated with treatment.
For this reason, please make sure, before assuming the carrier made an improper denial, to verify that indeed the claim was sent with the proper modifier. If there was no modifier 25, that would be your own omission and you would need to resubmit the claim with the proper modifier.
How to Appeal: The Letter
Assuming you have coded the claim properly with the appropriate E&M code appended with modifier 25, you should start with a standard appeal that the services were distinct and separate, and would indicate payment of each. Your appeal should include the following statement:
It is reported in the CPT manual (2020 Professional Edition page 746) that the CMT procedure includes a pre- and post-manipulation patient assessment. However, the evaluation and management service performed on (date) was not of a routine nature; the evaluation and management service provided was a separately identifiable evaluation and management service, above and beyond the usual pre-service and post-service work associated with the manipulation procedure.
This separate and distinct nature of the exam was clearly indicated on the billing claim form with the evaluation and management code appended with modifier 25.
A detailed and separate examination was necessary and beyond the scope of the pre-manipulation assessment. A copy of the original claim and actual examination is enclosed so you may verify the evaluation & management service of 99203 was clearly significantly separate and distinct from the treatment provided on the same day.
If there is an indication that the service was part of post-surgical service, that also should be indicated in the letter, but this type of denial can often be reversed with a phone call to provider relations.
A Final Method: Splitting Claims
A final method I have been tipped toward comes from several offices and billing services. They have found that simply splitting the claim, with one claim form for the E&M with modifier and then a separate claim for the treatment, seems to bypass the denial. This is not a typical method of billing, but not prohibited and seems to bypass the system for making this denial.
I have been told directly from Blue Cross and Blue Shield of Illinois that the denial is an error in the system and should not occur, and that they are working on it. (How long does it take, as this has been an issue for an extended period?) But it does make sense that a split claim works. I want to be clear that you are billing the same dates of services with modifier 25 on the E&M service, but simply putting the E&M coding and treatment services on separate claim forms.
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