# EPSDT visits Modifiers EP & 25



## jotten

I am having some difficulty with on of our Medicaid payers, they sent us a provider update stating that we can bill a preventative EPSDT visit with a level 1 or level 2 office visit if diagnosis warranted it. My understanding is that when a EPSDT visit is billed we place the modifers EP & 25 on that CPT code (ie: 99392) when we also preform other procedures (vaccines vision etc) IF the provider also discovers another problem (rhinitis) and does a lower level office visit (per the provider update) we can also bill an E/M visit with a modifier 25. 
Both the EPSDT visit and the E/M are being denied as incidental to the vaccine admin. code. My question is can I place modifier 25 on BOTH EPSDT visit AND E/M code or only on E/M and no modifier on EPSDT code?
Example: 99392 EP 25 V20.2       OR          99392
             99211 25     460                        99211 25
             90744         V20.2                     90744
             90648         V20.2                     90648 
             90471         V20.2                     90471
             90472         V20.2                     90472

All of that is a bit confusing I apologize, but any help given would be GREATLY appreciated!!


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## OCD_coder

I would hesitate using a 99211 with any of the services as this is a red flag for many of our carriers.  If the provider is seeing the patient, the lowest level they should bill would be a 99212.  I refer to the guidelines in the CPT manual that states "Code also significant, separately identifiable E&M service on the same date *for substantial problems requiring additional work *using modifier 25 and (99201-99215)".

The 99211 really requires no substantial additional work by the provider, this is work performed by the nurse typically.  So I would need to see the documentation you have to really support a separate E&M before commenting further. I look for two independent notes that can be reported in separate paragraphs for the 2nd E&M.


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## sarahjanejones

Which state?  I have worked in IL and AR and the Medicaid programs are very different as far as the billing is concerned.  

I can give you an example of how it would be billed in AR:

99392-EP-U2 V20.2 (has to go on an EPSDT claim form so we have to add an "ailment" in our system so it sends correctly)

90648-EP-TJ V03.81 (sent on a regular CMS-1500, no ailment needed)

99212-25 472.0 (sent on a regular CMS-1500, no ailment needed)

I know one of the keys with our system is making sure the level of service, 99212-25, does not go on the EPSDT claim (with the ailment).  If it does, it will be denied every time.  

I hope this helps and didn't just make it more confusing.


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