Same-Day E/M and Minor Procedure Denied as Bundled
On March 12, a 58-year-old patient with a Medicare Advantage plan was seen in a primary care office. The provider billed 99214-25 for management of hypertension and type 2 diabetes and 11402 for same-day excision of a benign arm lesion. The payer allowed and paid 11402 but denied 99214 with CO-97, stating the E/M is included in the procedure. The EOB is dated June 2. The office visit note documents a separate history, exam, and medical decision making for the chronic conditions, and the procedure note is separate. The payer's provider manual states that a significant, separately identifiable E/M service may be reported with modifier 25 and that appeals must be filed within 90 days of the denial date. The practice's billing policy requires review of NCCI edits before appealing. The account balance is $185, and the patient has not been billed. The provider asks whether to appeal, write off, or bill the patient.
1. What is the correct next action on the CO-97 denial, and what specific documentation and modifier support should be included in the appeal?
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Appeal is the best first step if the note supports a separately identifiable E/M. CO-97 means the payer considers the E/M included in the procedure. The defense is not a generic modifier 59; it is modifier 25 on 99214, supported by documentation showing a distinct history, exam, and medical decision making for the hypertension and diabetes, beyond the pre-procedure evaluation. The appeal should include the office note, procedure note, the original claim, the EOB, the NCCI edit screen, the payer policy allowing modifier 25, and a letter mapping the documentation to the elements of a significant, separately identifiable E/M. If the record shows the visit was only for the lesion, modifier 25 is not supportable and the $185 should be written off as a provider adjustment. Do not bill the patient while the denial is a provider documentation or billing issue.
2. Using the dates given, what is the appeal filing deadline, and how should the practice document timely filing?
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The denial date is June 2, and the payer allows 90 days, so the appeal must be filed by August 31. Count from June 3 as day 1: June 3-30 is 28 days, July adds 31 (59), and August 31 is day 90. The practice should submit the appeal before the deadline and keep proof: the appeal letter, fax confirmation or electronic appeal tracking number, the EOB, and the date sent. If the appeal is not filed by August 31, the payer will likely uphold the denial as untimely, and the practice cannot shift the loss to the patient. A calendar tickler at 30, 60, and 75 days reduces that risk.
3. Assume the documentation shows the E/M was performed solely to decide to remove the lesion and no separate chronic condition management occurred. How does that change your answer?
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If the E/M was performed solely to decide whether to remove the lesion, there is no significant, separately identifiable E/M service. The correct action is to remove modifier 25, not appeal, and write off the $185 as a provider adjustment. Reporting 99214-25 without supporting documentation would be an unsupported claim and could create compliance risk. The patient should not be billed because the denial is not a patient-responsibility issue; the service was bundled into the procedure payment. A brief note in the account should explain the write-off and the documentation review.