Pediatric Coding Alert

The preventive-medicine services codes (99381-99397) are, by definition, asymptomatic or associated with only minor problems. As soon as you begin treating a medical problem you will have history, exam and medical decision-making, which are the elements for an office visit code (99201-99215). Many pediatricians for years have accommodated their patients by charging a higher level office sick visit instead of a well visit so that insurance carriers would pay. (Most fee-for-service plans never used to cover well visits). But this is fraud. Now well care is frequently covered; thats one of the pluses of managed care. However, it is commonly not covered on a per-visit basis; rather, the child typically is only allowed a certain number of preventive-medicine services per year. And to compound the problem you must determine how to bill for a well visit and a sick visit during the same day, which is a common coding challenge in pediatrics.

Lets say a child is seen for a well visit in the
morning, and then comes into the office in the afternoon because of a fall. This situation was presented by Susan Ruppert, a biller for Warren Pediatric Associates of Warren, NJ.

The answer is to use modifier -25 on the office visit. This modifier indicates that a significant, separately identifiable evaluation and management service was performed on the same day. Note that the symptom or diagnosis can be the samethey do not have to be different for the two codes. In the case of a well visit and a fall, these are obviously completely different.

Many managed care plans balk at having to pay for two E/M services on the same day. But CPT clearly explains how this is to be done in the preface to the section on preventive-medicine service. If an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive-medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201-99215 should also be reported. Modifier -25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the preventive-medicine service. The appropriate preventive- medicine service is additionally reported. This is on page 32 of CPT Codes and should be copied and sent to health plans who dont believe in paying for two E/M services on the same day.

To use modifier -25, list the preventive services CPT code first with no modifier, and with a diagnosis code of V20.2 for the routine physical or V70.3 for a sports physical, says Thomas Kent, CMM, former office manager for a pediatric practice, and president of Kent Medical Management, a coding and management consulting company. Do not place any sick diagnosis codes here, Kent stresses. List the office visit second, with the -25 modifier to designate that the service is separate from the well-care visit. List the diagnosis codes for the problems treated during the sick visit (i.e., in this case, the fall). Finally, list any additional procedures performed or lab tests next.

Separate Documentation is Essential

How the pediatrician documents these two encounters is vital, explains Kent. Dont mingle notes from the two visits. It is important that the note for the sick visit be completely separate from the well-visit documentation, he says. There are two ways to do this: (1) by drawing a line at the bottom of the physical-exam sheet and completing the history and exam relevant to the illness with the medical decision-making below this line, and (2) by returning to the progress notes to complete the history relevant to the illness with the medical decision-making and referring to the well-visit page for the applicable exam results. Either system clearly distinguishes the sick visit from the well, and easily identifies the components which support the level of office visit performed, says Kent. This is the documentation which wins appeals.

Educate Payers to Win Appeals

Modifier -25 is something that many practicesespecially pediatricians, who dont deal with Medicareare starting to give up on, just as theyre starting to first use it. This is because the reception from private payers has not been good. But if you send the payer the copy of the page from the CPT manual which has modifier -25 defined, you may have better luck.

Medicare accepts modifier -25, and commercial carriers should, too. There are some practices which are billing for two visits done on the same day, without using any modifiers, and getting paid for themhowever, these practices are sending documentation with the billing. They are sending copies of doctors notes and descriptions of what happened (a well visit in the morning and a fall in the afternoon, for example) to show that the patient was there two separate times.

There are some practices which feel modifier -25 should be used if a patient leaves and returns the same day, but not if a patient comes in for a well visit, and then at the end of the exam, the mother says, I wanted to talk to you about my childs stomachaches. Two separate eventsthe well visit and stomachache are taken care of during one encounter. But the fact is that many of these should be billed separately. The fact they occurred during the same visit should make no difference.

Use Caution When Billing For Both

The example of the well visit and the fall clearly does require two charges and modifier -25. But there are also many times when you should not bill for a well visit and an office visit. A diaper rash which requires Lotrimin is not significant enough to bill for a separate visit.

Use the following criteria when billing for an office visit as well as preventive-medicine services:

- dealing with a complex problem,
- prescribing medication,
- ordering diagnostic tests, or
- recommending a consultation.

If they are truly unrelated, significant, and separately identifiable, both causes for the visit (i.e., the well child exam and the fall) merit being billed, using modifier -25. At the root of the problem is the fear that parents will be upset if they get billed for both. And you do have to bill the parent if the insurance company doesnt payyou shouldnt write it off. If some insurance companies are paying you for modifier -25 and some arent, and you write off the fees for the ones that arent, you will be discriminating, and penalizing those plans with more generous benefitssomething at which health plans take umbrage. Instead, you should take the view that the pediatrician is entitled to be paid for both services, no matter who is paying the bill.

Notify Parents

So practices that want to get paid for both services need to inform the parents that they may be responsible for these charges. The important point here is to notify parents of this change in billing patterns before the pediatrician sees the patient, says Kent. You must provide this notice at several levels to reach the majority of your parent population.

The first level is written notification. Kent recommends providing a financial statement to all parents that describes charges for a returned check, charges for late payments, collecting co-pays before the visit, and a statement about sick and well visits. Here is an example of how a statement on billing sick and well visits on the same day might read:

Sometimes a child is ill on the day his/her physical is scheduled. When this occurs you have a choice. You may bring in your child to be seen and treated for the illness. We will reschedule the physical for another day. Dr. Jones recommends this option for complex illnesses or problems which you wish to discuss at length with Dr. Jones. When your child has a simple illness such as an earache, sore throat, or fever, we can usually treat your childs illness and complete the physical on the same day. Please be aware that these are two separate visits and will be charged separately. Please notify the receptionist of your childs illness and your choice to reschedule the physical or be seen for both visits together. Thank you for your cooperation.

Screen Your Appointments

The second level, says Kent, occurs when the appointment for a physical is made. You should have your receptionist ask: Does your child have any complaints or illnesses you wish to discuss with Dr. Jones? This is very important, notes Kent. We want to train our parents not to view the physical as a time to haul out a laundry list of problems they have been saving to discuss, he adds. As most physicians have limited availability for well visits, they are usually booked a month or more in advance. If a parent answers yes to the question, the receptionist can then offer a sick-visit slot which is available in the next several days. Most parents are pleased to have their child seen sooner for the problem, says Kent. When a parent insists on waiting for the well visit, have the receptionist reiterate the choices.

The third level of notification occurs when the child is brought in for an appointment. Have the receptionist again ask if there is an illness or complaint to be discussed, says Kent. If the answer is yes, the parent should be offered the choice of rescheduling the physical for another day, or treating both today with two separate chargesone of which the parent may be responsible for.

The first year of this kind of policy will require some leniency as everyone is learning new procedures, says Kent. However, once this practice becomes the norm, it will be accepted.