Modifiers - Another question

[Guest guest]

I submitted a claim to BCBSGA which included the following codes. 99393 V20.299213 – 25 493.00, 314.01, 784.029130 842.11 The child came in for their regularly scheduled checkup and Med refills on their ADHD & exercised induced asthma. While there my office manager pointed out that the child was 9 months overdue for a well-child visit and need immunizations according to the accepted vaccine administration schedule. When I got in the room I found that the child had an icepack on their right middle finger, so I inquired why he had ice on his finger and discovered that he had jammed him finger in gym just prior to coming to the office. Believe it or not, mom had planned to take him to the ER to have the finger checked after finishing at my office. I thought that was crazy, he was already at my office, whey should there be an ER charge as well. I reviewed the update behavioral episode sheets from the child’s teachers and discussed whether he had experienced any problems with his ADHD medicine or his asthma meds since last seen and documented that he had not. I then wrote a separate note about my exam of his finger including the review of the x-ray of the hand that I ordered that day and determined that the finger was sprained and that a simple sugar tong splint for a week to 10 days along with normal RICE recommendations was appropriate. Said splint was applied by me. I then completed a 15 year old well child exam complete with vision screen using a Snellen Whole Vision Screener which does color, near & far vision and depth perception and peripheral vision. Dietary habits and exercise guidance was given to the patient and the mother. A Teen behavioral screen to screen for high risk behaviors, drug & alcohol use was also done. A full physical exam was completed to round out the visit. All total 1 hour and 15 minutes was spent with the child. 3 separate notes were completed using my standard progress note, procedure note and well child form for 15 -16 year old male. I did not charge for the vision screen since I don’t normally bill this separate from the well child exam. I initially got a denial from BCBSGA stating that the well child exam was bundled into another paid service on the same date of service. We immediately appealed the denial of the well child visit and yesterday we received a denial of the appeal stating that the claim was paid appropriately along with a copy of a BCBS policy that indicated that Evaluation and management services were included with on the day of other procedures performed. It went on to indicate that surgical procedures have an inherent assumption that an evaluation and management service has been performed to diagnoses and determine appropriate management of the problem being treated by the associated surgical procedure. 29130 has a global period of 0, and I truly feel I met the separately identifiable CPT guideline with the way I documented this encounter. What did I do wrong in billing this encounter? Am I right that these 3 procedures should be billed and paid separately or is BCBS right that the preventative medicine visit is bundled into the other 2 paid procedures? I received reimbursements of $42 for the splinting and $59 for the E & M. The well child was listed as denied/bundled. What language should I include in my 2nd tier appeal letter, if by consensus, it is thought that I did indeed bill these services correctly.?? The reimbursement for the well child exam should have been about $105. I sure am glad that the mom decided to take the child to the health department for his vaccines since BCBS indicated that they did not cover vaccines for children over the age of 7 under this patient’s policy. Beth Sullivan, DORidgeway Family PracticeCommerce, GA 30529