The importance of linking each CPT service provided to a distinct International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code. This clearly supports the medical necessity of furnishing the E/M-25 service separate from another procedure or E/M service. However, while a separate ICD-9-CM code may help to support medical necessity for the 2 distinct services, CPT points out that it is not always required. Under the guidelines for the Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions section (90760–90779), it states that different diagnosis is not required to use modifier 25.
Some insurance companies may require separate co-payments on both services. Although one of the co-payments may be dropped if the patient appeals, this unfortunate requirement is subject to the family’s plan benefit design and is not controlled by you, the provider. You are contractually obligated to comply with the plan’s requirements. It should be pointed out to the family that there would be another co-payment if the patient returned for another encounter to address the problem. This would require a significant additional investment of time and would be inconvenient.
A 5-year-old boy is seen for his preventive medicine visit. All necessary components of a preventive medicine E/M visit are provided including hearing and vision screening, appropriate laboratory tests, and immunizations. He has diagnosed attention-deficit/hyperactivity disorder (ADHD) and is on a stimulant medication. The patient is evaluated for his ADHD, and multiple parent concerns are discussed. A medication increase is made and follow-up arranged in 1 month. Fifteen minutes of face-to-face physician time is spent in counseling for this problem, addressing parent concerns and behavior management.
Complete documentation of the preventive medicine visit is made on an age-appropriate preventive medicine template. The ADHD is addressed with separate documentation on the back of the template form with careful notation of the 15 minutes devoted to counseling for this diagnosis.
Preventive medicine Well-child visit (5–11 y)
(15 minutes) ADD with hyperactivity
A 15-month-old girl presents with a fever (103°F) and mom states the girl has been tugging at her right ear for 2 days. A detailed history is obtained and a problem-focused examination is completed. When the doctor examines the ears he notices that the middle ear is very inflamed (pus is present) and the child is extremely uncomfortable. The doctor decides to administer ceftriaxone sodium to the child. The final diagnosis is acute suppurative otitis media without rupture of eardrum.
Some carriers, such as Ohio Medicaid, continue to fail to recognize modifier 25 and its appropriate use. Therefore, to get paid for seeing Medicaid patients with significant concerns, another visit on another day will be required for these patients’ Early Periodic Screening, Diagnosis, and Treatment visits or their medical concerns. It should be pointed out that some Medicaid managed care companies may allow and pay for these services consistent with the CPT guidelines.
The bottom line is to maximize your efficiency seeing patients and maximize their convenience in your medical home by providing medically necessary E/M-25 services at the time of another significant and separate E/M service or procedure. However, know your payer and its policy with this complicated coding area. You don’t want to get caught not receiving payment for the work you do or with a potential Medicaid payback.