Pediatric Coding Alert

Speaking to the medical director of your managed-care company will help you get paid for a well visit and an office visit on the same day using modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Scott Cuming, MD, FAAP, learned this first hand at his pediatric practice in San Antonio.

A child came to Cumings practice for a well visit, and in the course of the visit, the mother mentioned some school problems. It was clearly a case of attention deficit/hyper-activity disorder (ADHD) that needed to be medicated, says Cuming. If that comes up, you need to do a lot of extra work, explaining to the parent what the disease is and how the medication works. I spent an extra 60 minutes talking about ADHD to the mom, and I billed a CPT 99214 and a well visit with a modifier -25. I explained to the mother up front that she might have to pay two co-pays, he says

But the claim was denied, and Cuming called the medical director of the managed-care company. I explained that I could have told the mother to come back another day for the ADHD evaluation, says Cuming. And I asked if that was [the companys] policy. If thats what you want, I told the medical director, Ill do it, but I want a letter saying its what you want, so I can explain to parents that this is your policy, not mine. For good measure, Cuming mentioned that he thought that employers should know that this was the companys policy as well. The claim was paid.