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Mary Posted Tue 13th of August, 2013 20:43:08 PM


SuperCoder Answered Thu 15th of August, 2013 16:18:05 PM

If your specific Medicaid provider requires it - you have to contact them for their payer-specific rules since Medicaid rules vary by state. However, in general, according to CPT, a physician may bill a sick visit (office or other outpatient services codes 99212-99215) in addition to a previously scheduled preventive medicine service (99381-99385 and 99391-99395) if the presenting problem is significant enough to require additional work to perform the key components of a problem-oriented E/M [evaluation and management] service and modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is attached.

As with any E/M service, the severity of the diagnosis, intensity of medical decision-making and time spent on counseling and coordination of care determine correct coding. Because differentiating the office visit exam from the preventive medicine services visit exam can be problematic, documentation must rest with the history of the present illness and the medical decision-making connected with that illness.

Mary Posted Thu 15th of August, 2013 20:49:22 PM

My question is still on the floor due to if em applies !help which em codes would apply from low level and up. There are many and fishing for the correct ones would be another issue

Thank you

Mary Posted Sun 18th of August, 2013 12:59:55 PM

My interest in supercoder is I am in florida a child comes in for his well child and also is sick. Please I have tried 99213-25 along with 99392-25 yet the 99213 isn't being paid Is there a prolonged time which would apply if so what code is that and what modifier. or how is this done.

SuperCoder Answered Mon 19th of August, 2013 16:38:35 PM

You should select the appropriate well and sick E/M codes based on the documentation. There are prolonged time codes if the physician appropriately documented the time spent and it goes beyond what's published as a standard for each E/M code. In your case, the modifier 25 only needs to go on one code, it appears you billed it on both. If the physician performed the elements required for both 99213 and 99392, you would report 99213-25 linked to the sick diagnosis code, as well as 99392 linked to a wellness code such as V20.2.

Mary Posted Thu 29th of August, 2013 10:42:37 AM

all our well visits are now with a modifier 25 or it will not pay. So I am looking for once again how to bill this well and sick Medicaid thank you

SuperCoder Answered Thu 29th of August, 2013 11:01:48 AM

What is the reason code for the denial on your EOB?

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