Pediatric Coding Alert

A classic pediatric coding dilemma is the well visit that turns into a sick-well visit combination. The well visit for a child who has a medical problem requires extra work and time. Bill for a preventive-medicine visit (99381-99385 and 99391-99395) and a sick visit (99201-99215) on the same day by attaching modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the sick visit code. 

 
Your insurance company may deny the claim initially, and although more are recognizing modifier -25, they still dont like it. Be prepared to send in documentation with an appeal.
 
The best documentation is the medical record, which has the well visit written on one page, and the note for the sick visit written on another, says Thomas A. Kent, CMM, CPC, president of Kent Medical Management in Dunkirk, Md. The physician notes should show, This is what I did for the well visit, and this is what I did for the sick visit, Kent says. If the practice really wants to fight for modifier -25, that kind of documentation will support the services as being separately identifiable.
 
For example, a child has an ear infection. The physician should refer to the part of the documentation for the well visit that relates to the ears, and document the ear infection on the page for the sick visit. The physician should write that he or she looked at the middle ear and the outer ear for the sick visit. Because the pediatrician performs a comprehensive exam for the preventive-medicine service, the additional physical examination of the ear is minimal, explains Richard H. Tuck, MD, FAAP, who practices with Primecare Pediatrics in Zanesville, Ohio, and is the founding chairman and current member of the AAP coding and reimbursement committee. Justification for billing the office visit with the preventive-medicine services is the increased medical decision-making and time, Tuck says.
 
On the claim, make sure to link the well visit diagnosis code (V20.2 ) with the well visit code, and the otitis media diagnosis code (38x.xx) to the sick visit code.
 
In the documentation, you must lay the groundwork to fight the denial.

Chronic Conditions

 
When a patient with a chronic condition such as asthma or diabetes presents for a well visit, coders may be tempted to bill a sick visit as well. Few pediatricians would give the same kind of well visit attention to a patient with serious asthma as to a patient with no medical problems. But does this mean that every preventive-medicine service visit for a child with a chronic condition gets an office visit with modifier -25 attached?
 
Most preventive-medicine service visits with a child with chronic conditions deserve an office visit as well, if the problem is an active one requiring attention, Tuck says.
 
For example, a child with chronic asthma on home aerosol and other medications comes in for a well visit; this is a good example of the appropriate use of modifier -25 on a sick visit combined with a well visit, Tuck says. On the other hand, a child who had asthma in the past but is not on any medication would not have an office visit that is separate from the well visit, so modifier -25 is not appropriate.
 
An office visit for a child with diabetes is another good example of when to use modifier -25. Even well-controlled diabetics will want to discuss management of the disease during a well visit, Tuck says. This would merit a sick visit in addition to the well visit. The condition need not be exacerbated or serious, he says. It just needs to be active.

 
The strongest case for modifier -25 occurs not during a well visit but during a sick visit in which another procedure is performed. For example, a child is injured and must receive a simple, small laceration repair (i.e., 12001* or 12011*) or a finger splint (29130). In addition, the pediatrician performs an office visit (99201-99205, 99212-99215) to make sure there is nothing else wrong with the child. Append modifier -25 to the office visit.
 
If you must choose a test case to fight for modifier -25 with your payer, choose one like the laceration case and not the well-sick visit combination.
 
CPT makes it clear in the descriptor for modifier -25 that you can use the same diagnosis on the office visit as the other service, as long as the other service is significant and separately identifiable. However, some insurance companies look for a different diagnosis. A good rule of thumb,  Kent says, is to use the signs and symptoms for the office visit, and the specific injury for the separate procedure.