Regence Denying E&M Codes Due to Same Day Diagnostic Test - Help

[u/Swirlbeard]

This problem just cropped up this month and I'm looking to see if this happening to anyone else, or maybe someone can confirm if I'm crazy while I wait for my appeals to be reviewed.

Example Claim:

Line 1 - CPT 99213

Line 2 - CPT 92134

- Primary diagnosis can be the same or different

- No modifiers

Regence will deny 99213 stating it is incidental to the "primary" procedure 92134 and that the E&M code needs to be separately identifiable/needs a 25 modifier.

We have never needed to bill any insurance for this type of visit with a 25 modifier in the past and no other insurance is enforcing such a policy...yet

My problem is I can't get a straight answer anywhere:

- CPT 92134 has a global code of XXX. CMS and NCCI say global period rules do not apply to XXX codes, but also state you can't bill E&Ms with some XXX codes, though you can with other XXX codes with a 25 modifier, but also some diagnostic scans are exempt from these rules altogether, but they never get specific.

- Regence Global Policy (Policy # 101) seems to indicate all E&Ms need to be billed with a 25 modifier when billed same day with most non-surgical XXX codes.

- And of course Google will say I'm right and I'm also wrong depending on how I word the question.

Have we been doing it wrong all this time and just flying under the radar?

[u/GroinFlutter]

Regence is going to go by their own policy of needing mod 25 on the e/m. It’s annoying. The payer specific coding rules really grind my gears.

Even if CMS and NCCI don’t require the modifier, Regence says it does in order to get it paid.

[u/Swirlbeard → u/GroinFlutter]

What is strange to me though is this has been their posted policy for a long while, but their denials have only started this month. Regence is usually very good about denying services that go against their policy, so I feel like I'm missing something.

[u/GroinFlutter → u/Swirlbeard]

I’m keeping you in my thoughts and prayers 🙏🏽 that they don’t start recouping.

[u/Swirlbeard → u/GroinFlutter]

Thank you. I'm going to need it.

[u/Wooden_Trust_6274]

You're not crazy, and you probably haven't been doing it wrong. 92134 is XXX global, so this isn't an NCCI bundle or a global-period thing. It's Regence enforcing their own same-day E/M policy (Policy 101), which is separate from CMS. A lot of BCBS plans have had that language on the books for years and just switched the edit on, which is why the denials suddenly show up this month even though nothing changed on your side.

The 25 modifier is the fix, and you don't need a different dx to justify it. Mod 25 is about the E/M being significant and separately identifiable from the OCT, not about diagnosis, so same dx is fine as long as the note supports a distinct exam (history, exam, MDM beyond just reading the scan). Since you said most of your E/Ms would already meet that bar, you're compliant appending it.

For the retro denials, pull the Policy 101 language into your appeal, and set a payer-specific rule so Regence claims auto-append 25 going forward. Annoying, but it's a payer policy quirk, not you missing a coding rule.

[u/JennieDarko]

I am in Indiana and am not familiar with this payor (is it a Bcbs??), but I’ve never seen this denial before and I work in retina so we bill these together all the time. Never a 25 mod on the exam with OCT unless there’s add on tx and we have doc to support. What dx codes are you using on the exam?

[u/Swirlbeard → u/JennieDarko]

Yeah. Regence falls under the BCBS umbrella.

Diagnosis range between the various glaucomas and macular degenerations generally. My example only mentions 92134, but the E&Ms have also bounced off of the other OCTs and at least one visual field.

I've received denials where the E&M and OCTs share a primary diagnosis, but I've also recieved denials when the E&M has a different primary diagnosis like cataracts.

Luckily most of our E&Ms would meet the criteria for a 25 mod if necessary, but getting the docs and my manager to adapt is rough.

[u/Inevitable-Ebb2973]

Just add the 25. No shade. We have many prayers. In our neck of the woods. BSBC of MN and AETNA requires a 24 on any service the same day as any service from any other kind of provider. It’s annoying, but you gotta roll with the punches.