Pediatric Coding Alert

Everyone uses modifier -25, but who uses it properly? Before you attach modifier -25 to a code, do you make sure you have proof that the pediatrician performed a separate and significant service? If you don't, your practice could face long appeals, payment refusals, or worse - audits.
 
In pediatric practices, no modifier is used more often than modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), but many pediatric coders aren't clear on how to use -25 appropriately, coding experts say.
 
"The most difficult issue surrounding modifier -25 is ensuring that the E/M service is truly separate and significant from other services the physician furnished on the same date," says Cindy C. Parman, CPC, CPC-H, RCC, co-founder of Coding Strategies Inc., in Dallas, Ga.
 
For instance, the documentation must clearly support that a surgical procedure and the patient evaluation are separate services, and the medical necessity for a separate visit must be clearly stated, she says. Follow This Lead
 
Here's a scenario that exemplifies the correct use of modifier -25 for a procedure:   An established 4-year-old patient pulls a pitcher off the kitchen counter at her home, causing a bruise and cut on her forearm. The pediatrician sutures the wound and also checks the child for other signs of trauma, performing a level-two E/M exam.  
 
For the repair of the girl's forearm, report 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or other extremities [including hands and feet]; 2.5 cm or less). Report the E/M exam CPT 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision making) and append modifier -25 to show that the laceration repair was separate from the E/M service.
 
You would use modifier -25 in this situation because the E/M exam is unrelated to the laceration repair, coding experts say. The accident caused the laceration, but the pediatrician didn't need to perform the E/M exam to determine that; she had to perform the E/M exam to make sure the accident didn't cause the child any other injuries.
 
If your documentation clearly supports two separately identifiable services, you can use modifier -25.

Learn 4 Carrier Guidelines Payers vary on the acceptable uses of modifier -25, so you should keep updated on relevant requirements. Many private carriers and HMOs accept modifier -25 when:

 1. one problem, finding or complaint prompts both an E/M service and a minor surgical procedure
 2. counseling and coordination of care occur on the same day, usually after a minor surgical procedure.
 3. there are [...]