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Pediatric Coding Alert

Modifier -25: How to Get Paid for Well and Sick Visits on the Same Day

- Published on Sun, Aug 01, 1999
The preventive-medicine services codes (99381-99397) are, by definition, asymptomatic or associated with only minor problems. As soon as you begin treating a medical problem you will have history, exam and medical decision-making, which are the elements for an office visit code (99201-99215). Many pediatricians for years have accommodated their patients by charging a higher level office sick visit instead of a well visit so that insurance carriers would pay. (Most fee-for-service plans never used to cover well visits). But this is fraud. Now well care is frequently covered; thats one of the pluses of managed care. However, it is commonly not covered on a per-visit basis; rather, the child typically is only allowed a certain number of preventive-medicine services per year. And to compound the problem you must determine how to bill for a well visit and a sick visit during the same day, which is a common coding challenge in pediatrics.

Lets say a child is seen for a well visit in the
morning, and then comes into the office in the afternoon because of a fall. This situation was presented by Susan Ruppert, a biller for Warren Pediatric Associates of Warren, NJ.

The answer is to use modifier -25 on the office visit. This modifier indicates that a significant, separately identifiable evaluation and management service was performed on the same day. Note that the symptom or diagnosis can be the samethey do not have to be different for the two codes. In the case of a well visit and a fall, these are obviously completely different.

Many managed care plans balk at having to pay for two E/M services on the same day. But CPT clearly explains how this is to be done in the preface to the section on preventive-medicine service. If an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive-medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201-99215 should also be reported. Modifier -25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the preventive-medicine service. The appropriate preventive- medicine service is additionally reported. This is on page 32 of CPT Codes and should be copied and sent to health plans who dont believe in paying for two E/M services on the same day.

To use modifier -25, list the preventive services CPT code first with no modifier, and [...]

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