Examination Denials

Q: I had a denial for examination (99204) of a new patient. On the EOB form, it stated that "the service billed is included in another procedure billed the same day." I do not understand this denial, as I am required to do an exam to ascertain the condition of my patient and formulate a treatment plan. I did perform a chiropractic treatment in the same visit, but that code was for my specific manipulation service. Are they right - do I not get paid for an exam when I bill it with treatment? If not, what did I do wrong, and how can I get my examination paid?

A: You are correct in that you must perform an examination to determine the patient's condition and course of care. But, a common error when billing for an examination the same day as treatment is to not include the modifier -25 on the exam code (in this case, 99204-25). This modifier is certification that a significant, separately identifiable evaluation and management service (examination) was performed the same day.

The reason this modifier must be applied is that all chiropractic manipulative services have an included component that is a pre-service, intra-service and post-service assessment. This assessment is for the typical short history review and evaluation performed on each visit, prior to and after the day's treatment. This assessment is not billed separately (as the more extensive evaluation done on the first visit and on re-examinations would be). It is for this reason that an examination (evaluation and management code) is not to be billed on every visit.

To correct this claim, you must resubmit the billing with the proper modifier. It should then be paid. Including a copy of the examination with the rebilling is also useful, as it will avoid further delays should the insurance company want to view the record of the separate examination.

Samuel A. Collins
Santa Ana, California