Claim Denial with Modifiers 24/58

Question:

I have been getting denied for office visits (99212-99215) billed during a global period. I bill the E/M code with a modifier 24, and/or 58 and the claims still get denied for “separately billed services/tests as they are considered components of the procedure. Separate payment is not allowed.” According to the conferences I have attended for KZA, we’ve been told that we can bill and E/M code with modifier 24, but the insurances do not cover it. Do you have any other suggestions on how to get these claims paid?

Answer:

Thank you for your question. Billing an E/M service during a global period can be tricky, especially when insurers bundle them into the procedure. Here are some strategies to improve claim approvals:

1. Ensure Documentation Supports the Modifier

• Modifier 24: Must show that the E/M service is unrelated to the procedure. If the visit is for post-op care, insurers will likely deny it.

• Modifier 58: Used for staged or related procedures, not routine post-op visits or visits unrelated to the procedure.

2. Check Payor-Specific Guidelines

• Medicare and private payors may interpret what qualifies as an unrelated E/M service differently.

• Some payors require additional documentation proving medical necessity.

3. Use Diagnosis Codes That Support Unrelated Services

• If the diagnosis code is too closely related to the procedure, payors may still bundle the visit.

• Consider adding supporting notes explaining why the visit was medically necessary.

4. Appeal Denied Claims

• If you believe the denial was incorrect, submit an appeal with detailed documentation.

• Include payor guidelines that support separate reimbursement.

*This response is based on the best information available as of 7/17/25.