Pediatric Coding Alert

 Last month, we used specific examples to help explain when two distinct problems do and do not warrant the use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). We also delved into the documentation requirements for reporting an evaluation and management (E/M) service when a new patient presents for a procedure.

Example: An established patient comes in for a routine immunization. The provider prepared the vaccines, sterilized the area and administered the correct number of CCs. A prescription is written for an anti-inflammatory and physical therapy is ordered for hip joint pain.

Some providers think the notes above warrant billing an E/M service along with the immunizations. “Just writing the prescription or finding a different diagnosis doesn’t get us to significant and separately identifiable E/M. We need a robust paragraph of evaluation and management,” says Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado, during his HEALTHCON presentation, “What Exactly Is a Significant and Separately Identifiable E/M?”

Better option: Let’s say the note had instead said something like this: “During routine visit, patient complained of hip joint pain. After the immunizations, we discussed duration of the pain, possible causes, and family history. I checked range of motion and degree of pain and discussed the advantages and disadvantages of physical therapy and anti-inflammatory medications. Wrote a prescription for both and ordered X-rays. Referred patient to an Orthopedist for further evaluation.”

The difference between the two sets of notes is clear. The patient came in for their preventive procedure and had a chief complaint of hip joint pain, which required a completely separate E/M. The work for each didn’t overlap, and the documentation clearly showed that there was both evaluation and management.

Reporting Separate Diagnosis Codes Is not Always Necessary

Sometimes, there are instances of significant and separately identifiable E/M services that don’t carry an additional diagnosis. “A separate diagnosis code is not necessary for the use of an E/M code with modifier 25,” confirms Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Example: Patient presents to the clinic for possible stitches from bumping their head. During the encounter, the patient mentions sudden dizziness and feeling sick to their stomach. The physician checks for additional head trauma that is significant and separate from what is needed to determine how deep the cut is for the sake of closing the wound. The physician discusses and assesses the symptoms, but the ultimate determination was that the patient has no serious injury. The pediatrician recommends the patient take the rest of the day off from school, get plenty of rest, and try breathing exercises if symptoms persist.

“The evaluation goes beyond what would be needed for standard sutures,” explains Johnson. “But the ultimate determination was that the patient was anxious about receiving stitches,” she says. There is no additional diagnosis code to report, but if the PCP clearly documents that there was a significant and separate E/M, that service is billable in addition to the wound repair.

Know What to Look for in the Patient Record

“Modifier 25 can be tricky to get used to determining,” says Johnson. Remember that the documentation must fully describe the additional E/M service. “If the documentation just supports the procedure, the use of an additional E/M with modifier 25 would not be appropriate,” she says. If you suspect the practitioner’s work warrants use of the modifier and their documentation does not, it’s important to communicate that to them directly so they fully understand what to document.

Documentation example: For an E/M service that is significant and separately identifiable from a procedure, an auditor is going to want to see that clearly in the notes. “If you’re a provider or you’re looking for something to communicate with your provider, I suggest a paragraph to physically separate the two services,” explains Lehrman. “This is my suggestion as an auditor. Begin the paragraph with something like this: ‘patient has a separate complaint today…,’ then after documenting the evaluation and management of that complaint, the last sentence should be, ‘This evaluation and management of the _________ was significant and separately identifiable from the procedure of ____________,’” he says.