Pediatric Coding Alert

Tip: Dual-service entries should include customary fees, even if claim will result in denial

Handling insurers’ modifier 25 policies the right way can help you capture entitled payments. Here are the facts you need to tackle this daunting task.

#1: Payers May Play by Non-CPT Modifier 25 Rules

You followed experts’ advice on documenting claims for dual E/M services and started making separate notes for these types of encounters. But will creating two-entry documentation pay off, wonders Carrie Soler, assistant office manager at A.V. Pediatrics, Allergy and Family Medicine in Lancaster, Calif. “Will our providers be reimbursed at full rate for each E/M code billed for same-day service?” she asks.

Answer: “First, it really depends on the contract,” says Chip Hart, director of  Physician’s Computer Company Pediatric Solutions consulting group. Unless the contract says otherwise, you should expect full payment.
 
Why: The RVU system makes no adjustment for codes with modifier 25. Although a plan may pay such claims as the policy allows, insurers that “follow CPT rules should be paying each CPT Code ‘in full,’ ” Hart says. “Part of the reason for making a distinct entry for the additional service is because that’s part of the overhead of the visit.”

#2: Two-Entry Charges Should Reflect Real Prices

Correct coding guidelines require you to code a two- E/M service as such -- with two E/M codes. Your charges should remain consistent, regardless of the number of E/M services the claim involves.

But some practices may accept aggressive advice in an effort to thwart modifier 25 denials by manipulating their pricing. Two tips masquerading in sheep’s clothing that you shouldn’t follow include:

• Enter a $0 charge for the sick visit service (99201-99215), and bill the preventive medicine service (99381-99397) above the contracted rate

• Split the well care charge in half and apply it to the sick visit.

Why not: These are horrible ideas, Hart says. Contracts may not allow this charge shifting. Plus, “raising your price in a single instance isn’t going to net a dollar of income,” he says.

Right way: Charge each E/M service at the usual amount (at least 20 percent above the contracted amount), Hart says.

#3: Full Reimbursement Is Improving

Recent settlements may lead you to expect court-ordered full reimbursement for dual E/M services. But these orders may not affect you. “Some insurance companies actually behave differently in different  parts of the country (United/Oxford, for example),” Hart says.

Good news: Reimbursement for same-day E/M services is improving. As part of Aetna’s settlement, the company is paying for a modifier 25-appended service with a preventive medicine service, Tuck says. “The insurer, however, is only allowing payment on claims that were originally filed with modifier 25,” he adds.

#4 A Good Appeal Includes These Pieces

CPT does allow reporting a significant, separately identifiable E/M service on the same day as another service: That’s what modifier 25 represents. When a health plan denies a sick visit as inconclusive to the well care portion of the claim, try these tactics:

• appeal -- Use an appeal template. Also include the physician’s two-entry documentation linked to separate diagnoses, and references from the CPT book and Pediatric Coding Alert modifier 25 articles.

• reschedule services -- Tell your patients to come back for the physical.

• outsource problem/ancillary services -- If you’re losing payment on problem-oriented portions that specialists could handle or services typically performed in conjunction with a preventive medicine service, refer patients for these services. For instance: Combat 99173 bundles by sending patients to the ophthalmologist for vision screenings, Hart says.