Why do third-party payers bundle treatment codes with E & M codes on the same visit and only pay the lowest code?
Do you often find that you "aren't getting paid for exams" or that third party payers are "bundling your exam" with the treatment for that day and paying you only for the treatment?
Let's look at the reasons why.....
There is a certain amount of "examination" that is expected each time the patient is treated (each daily visit). This is factored in and included as part of your spinal manipulation code.
UNLESS YOU SPECIFY OTHERWISE using coding and documentation it will be assumed that this is the only examination that took place and it will most likely be bundled and you will be paid for only the spinal manipulation.
If a treatment (e.g., 98940) is performed on the same day as an exam a -25 modifier MUST be added to the exam code. Example: 99203-25 (the -25 modifier indicates that the exam is separate and distinct from the treatment)
If the documentation for that treatment code is not separate and distinct from the documentation for the exam code the third-party payer will bundle both codes even if a -25 modifier is used on the exam code.
Why do they do this? The answer is simple.
Treatment codes 98940, 98941, and 98942 require documentation for the assessment (P.A.R.T), the adjustment, and the post assessment. If the exam documentation and the treatment documentation are combined the third-party payer can only assume the exam and treatment were NOT separate and distinct and will bundle and pay the lowest code.
How to properly bill and document a treatment and exam on the same day to prevent third-party payers from bundling:
To document the E&M code, use a Document Plus Health Questionnaire (HQ3) and Clinical Evaluation worksheet and follow E&M documentation guidelines
To document treatment, use a Daily Note
Don't let 3rd party payers bundle when it's not appropriate.
Get paid for the services you provide using great documentation!