Pediatric Coding Alert

Private payers may drop the modifier requirement forj medicine/service claims

You finally have a fail-safe policy to stop the nagging doubt over whether you should append modifier 25 to the E/M service on a claim that also involves a medicine code.

CPT: Many Medicine + E/M Claims Don’t Require 25

When you perform an office visit that is separate and distinct from a medicine service, “the E/M code does not typically require modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service),” says Richard H. Tuck, MD, FAAP, a nationally recognized pediatric coding speaker with PrimeCare of Southeastern Ohio. “You will not find any language to that effect in CPT or CPT Assistant .”

But your office may be in the habit of automatically entering 25 on all claims for same-day office visits with associated medicine services. Physicians have been increasingly using modifier 25 because payers have recognized the modifier and paid claims coded in that manner, Tuck says. “Thus, the modifier has become used more frequently than rules necessarily dictate.”

Tuck says the following medicine services are among those that CPT does not require to have modifier 25 on the E/M service code (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient …):

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

• hearing screening (92551, Screening test, pure tone, air only) 

• nebulizer training (94664, Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device)

• nebulizer treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device])

• vision screening (99173, Screening test of visual acuity, quantitative, bilateral).

CMS Echoes CPT Policy

Recently, the Centers for Medicare & Medicaid Services backed this less-use policy with a much-needed clarification. New guidance: As of Aug. 20, you should only use modifier 25 when the physician provides a significant and separately identifiable E/M service on the same day as a procedure with a global period, says Jim Collins, CPC, CHCC, president of Compliant MD Inc. in Matthews, N.C.

CMS Transmittal 954 states that modifier 25 “shall be used when the E/M service is above and beyond the usual pre- and postoperative work of a procedure with a global fee period performed on the same day as the E/M service.” Otherwise, “E/M services provided on the date of the procedure are inclusive unless a separately identifiable E/M services is provided on the same day,” says Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va.

You can identify codes that have no global period by looking at column “O” of the 2006 National Physician Fee Schedule Relative Value File. If the column designates the code with an “XXX,” which means “The global concept does not apply to the code,” CMS does not require you to use modifier 25 on an associated E/M service code.

Most medicine codes contain no global period. So according to CMS, you would not need modifier 25 on the E/M service code for all the above-noted medicine codes. Other commonly used pediatric codes containing “XXX” global days in the medicine section are:

• vaccines, toxoids (90476-90749)

• immunization administration (90465-90474)

• ECGs (93000-93010, Electrocardiogram, routine ECG with at least 12 leads …)

• post-bronchodilator (94060, Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration)

• vital capacity (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation).

Exception: CPT does state that certain medicine codes do require modifier 25 on the E/M service code. These include injectables (90760-90779). “If a significant, separately identifiable evaluation and management service is performed, the appropriate E/M service code should be reported using modifier 25 in addition to 90760-90779,” according to CPT’s introductory notes to the subsection “hydration, therapeutic, prophylactic and diagnostic injections and infusions.”

Expert Recommends Prudence

You’ll have to wait and see whether the CMS guidance on medicine codes other than injectables trickles down to private payers. If a payer doesn’t require modifier 25 on these claims, “you’re really making extra work for yourself by including it,” Tuck says.

The modifier 25 clarification may slightly help, says Chip Hart with the Winooski, Va.-based Physician’s Computer Company, which supports and develops pediatric-specific software. “Offices will have a CMS rule to point to.”

But if insurers play by their own rules and require modifier 25 on service claims involving a medicine service, it might not be worth a fight. “If submission doesn’t work without modifier 25, resubmit the claim using the modifier before picking up the phone, says Charles A. Scott, MD, FAAP, pediatrician at Medford Pediatric & Adolescent Medicine PA in Medford, N.J.