Pediatric Coding Alert

5 tips walk you through reporting dual-service claims

When a claim requires modifier 25, these insider tips will help you identify the modifier's details: which code to append it to and when to use the modifier.

1. Identify Claim Makeup to Solve 'Which'

All the talk of when to use and not use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) may have muddied the modifier's fundamentals. "Should I attach modifier 25 to the well visit code or to the 'sick' code?" asks Shoeb Amin, MD, FAAP, with Bloom, Amin and Banker in Haverstraw, N.Y.

Catch: Modifier 25 can be applicable on either a preventive medicine service code (99381-99395) or on a problem-oriented office visit code (99201-99215, Office or other outpatient visit ...). The answer depends on the claim makeup.

2. Put 25 on Problem E/M Following Well

Here's when you should append modifier 25 to the problem-oriented visit. Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, N.J., says to put 25 on 99201-99215 when the encounter meets these criteria:

1. the pediatrician provides a sick visit at the same time as a preventive visit

2. the preventive visit was the reason for the scheduled visit.

Why: The pediatrician provides the sick service "secondary to the preventive," Brink says. Therefore, the 25 goes on the sick visit to indicate that the problem E/M is significant and separate from the preventive medicine service.

How it works: During the course of a preventive medicine service, a patient has a medical complaint, such as a fever and a cough. "The physician then performs a separate E/M to address the medical problem," Brink says.

3. Bill Problem Part When 3 Criteria Are Met

You should only charge the sick visit (in addition to the preventive medicine service) under these conditions:

1. "The physician performs a separate E/M service, meaning all three key components of history, examination and medical decision-making for a new patient office visit (modifier 25 on 99201-99205) and two out of these three key components for an established patient office visit (modifier 25 on 99212-99215)," Brink says.

2. Documentation for the problem-oriented portion (modifier 25 on 99201-99205 or modifier 25 on 99212-99215) is separate from the preventive medicine service (99381-99395). "You cannot 'double-dip' between the preventive medicine service and the sick visit," Brink says.

3. The encounter involves a separate and distinct problem as determined by the following guidelines recommended by Richard H. Tuck, MD, FAAP, a national pediatric coding speaker and educator.

A. The problem involves treatment with a prescription.

B. The problem would have required the patient to return for another visit if you had not addressed it at this encounter.

C. You have a separate and distinct ICD-9 diagnosis for that problem.

4. Use 25 When Well Results in Procedure

Make sure you always append modifier 25 on a preventive medicine service code (99381-99395) when the encounter also involves a procedure. Modifier 25 indicates that the well visit is separately identifiable from the procedure, such as:

• chemical cauterization of granulation tissue (proud flesh, sinus or fistula) (17250)

• removal impacted cerumen (separate procedure), one or both ears (69210).

5. Follow Payer Policy for E/M and Screening

Many plans also require you to append modifier 25 to 99381-99395 on claims involving a screening, Tuck adds. "In these instances, however, the modifier is not technically required by CPT."

You may need to append modifier 25 to 99381-99395 on claims for a preventive medicine service and a:

• screening -- hearing (92551, Screening test, pure tone, air only) and/or vision (99173, Screening test of visual acuity, quantitative, bilateral)

• developmental testing -- 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report).