Re: UHC and Aetna denying office visits as "part of other procedure"

[Steve Verno]

Im sorry, I disgree with two statements.

Using modifier 25 does not gurantee payment.  Modifier 25 is one of the most abused modifiers and is under the watch of the OIG.  Modifier 25 simply records that the E/M is a significant and separate visit but in some cases this may not be so. 

As a patient, I have two doctors billing me for high level E/M visits, yet the purpose of both visits were not for an office visit.  One visit was for a diagnostic test,  the other was for surgery.  In addition, the documentation doesnt support the level of visit being billed.  When challenged with CPT and CMS Documentation guidelines, the office managers both responded that they can bill the E/M because they used modifier 25.  Both doctors are under investigation for fraud. 

an office visit is NEVER included in an injection. 
If the purpose of a visit is an injection, you do not bill the office visit because it cannot be justified.

Just because an insurance company denies, doesnt mean they are right.
There are also extenuating circumstances such as insurance contracts, coding policies that a doctor agreed to accept.

Here we have the main reason why forums have limitations on what we can present as answers.  We dont know what was documented and we dont have access to the chart, the original claim, or the EOB.  Therefore we cannot say you can bill AAAAA, BBBBB, CCCCC or DDDDD.  We dont know if the codes being billed are correct in the first place.   

[Steve Verno]

The problem is, the contract may have language that your doctor agreed to the insurance companies coding policies, even though they may contradict industry coding standards.  Hence, no appeal. 

[Steve Verno]

Yes, you fight back and never give up
Both aetna and united are wrong
use your NCCI edits to fight back

Now, if your doctor is contracted,then fighting back may not be possible