05/12/2022

Empire BCBS Denial for 99203 with Modifier 25 Appended

The new OV charge was denied, see below. How can this be? Ins. denied, and upheld denial on appeal, for 99203-25 "because it is not eligible for separate reimbursement when billed the same day as a major procedure with a 90 day global period. The -25 modifier does not bypass this edit."

Blue Cross denied the procedure code correctly for misuse of modifier 25 on the same day of a major procedure.  Modifier -25 is only appropriate to append to an E&M code reimbursed separately when it is billed with a minor procedure (a service that has a global period of 0 or 10 days). When a provider decides at the time of service to perform a major procedure (that is defined with a global period of 90 days), the E&M code needs to be appended with modifier -57. A corrected claim needs to be submitted with the modifier corrected and the office visit should be paid in addition to the fracture procedure.