Don't have a TCI SuperCoder account yet? Become a Member >>

Pediatric Coding Alert

Steer Clear of Screening and Well-Check Modifier Mishap

Modifier 25 is the way to go with E/MsYou may no longer have the option of using modifier 59 to get around payers that include a screening with a preventive medicine service.CPT 2008 puts an end to using modifier 59 (Distinct procedural service) on the screening code to indicate that the screening was a distinct procedure from the preventive medicine service. Keep your modifier 59 use on the up-and-up by adhering to these guidelines.Limit Modifier 59 to Non-E/M Code CombosThe AMA added "non-E/M" to modifier 59's description to further distinguish it from modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). The description clarifies that you should use modifier 59 on procedure codes -- namely non-E/M services by stating "that a procedure or service was distinct or independent from other non-E/M services," says Catherine A. Brink, CMM, CPC, CMSCS, president of HealthCare Resource Management Inc. in Spring Lake, N.J.Rule: You can use modifier 59 only to distinguish a procedure from a non-E/M service, not a procedure and an E/M. "Modifier 25 is used to report services or procedures separate from the E/M service, not 59," says Janet Smith, CPC, RHIT, coding educator for the Tennessee Chapter of the American Academy of Pediatrics in White House.When reporting a screen, such as hearing (92551, Screening test, pure tone, air only), vision (99173, Screening test of visual acuity, quantitative, bilateral) or developmental (96110, Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report), with a preventive visit, "the appropriate modifier to use is modifier 25 on the preventive code" 99381-99385 (new patient preventive medicine service) or 99391-99395 (established patient preventive medicine service), Smith says.Qualify as Different, SeparateYou'll have to restrict your modifier 59 use to certain circumstances. CPT now specifies that your documentation must support a:• different session• different procedure or surgery• different site or organ system• separate incision/excision• separate lesion or• separate injury (or area of injury in extensive injuries).With the revision, the modifier's applicability narrows from appropriate modifier 59 circumstances "may represent" to "documentation must support." Some experts previously suggested that Appendix A's inclusion of the above scenarios was merely as examples, not qualifying circumstances. "I have always felt modifier 59's use was limited to those examples," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders. "The 2008 CPT guidelines make the modifier's guidelines more crystal-clear."Example: A pediatrician treats a patient for a first-degree burn on her elbow and a second-degree burn on her hand. Because the Correct Coding Initiative (CCI) indicates that 16000 (Initial treatment, first-degree burn, when no more than [...]