Pediatric Coding Alert

When a child is in for a well visit and also has a problem that the pediatrician knows justifies an office visit, how can your pediatric practice be reimbursed for both? Can you bill for otitis media discovered in the course of a well visit? Or must the problem be more extensive? Sajjad Iqbal, MD, a pediatrician in practice in Ridgewood, N.J., has had success getting paid in these cases by using modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Pick Your Battles

Early on in the well visit, says Iqbal, he gets a sense of whether there is going to be a sick visit as well. I usually wont use modifier -25 for cases that are small, such as otitis media at the time of a well visit, he says. This is partly a matter of choosing your risk. The insurer, if it will pay only for one of the visits, will pay for the lower-paying service. So if you bill a well visit with, for example, a 99212-25, you risk losing the fee for the well visit and getting paid only the small fee for the CPT 99212 . You run a risk just by filing, he says. So the key is to pick your battles. Only use the modifier -25 with cases that are truly worthy of it, bearing in mind that most private payers simply refuse to honor the modifier -25 at all. But Iqbal has had some success getting modifier -25 paid. And in some cases, he is still fighting. Here are his test cases.

Case #1: An established patient came in for a well visit. During the exam, Iqbal discovered that the patient was severely anemic. The patient turned out to have severe iron-deficiency anemia (280.1)but the pediatrician didnt know that at the time. The pediatrician spent a lot of time on the visit, ordering lab tests and, in general, doing a lot more for this acute problem than normally would be done during a well visit. Iqbal billed a 99214-25, as well as the well visit. The payer, Oxford, denied the sick visit but paid for the well visit (in a departure from the standard HMO response to the modifier -25, which is to pay for the sick visit, but deny the well visit).

Iqbal contacted Oxford and was told that their policy was not to honor modifier -25. So I wrote to the CEO, who used to be the medical director, says Iqbal. I explained that there was extensive extra work involved. I sent a letter, plus the documentation in the chart, the documentation of my time, a copy of the original claim and the explanation of benefits (EOB). And I was pleasantly surprised to get a letter back saying that Oxford does not honor modifier -25, but that in my case, there was clearly a need for an exception.

Case #2: In another situationalso involving an Oxford subscribera new patient came in whose primary problem was failure to thrive. The child came in for a well visit. Iqbal ordered lab work and referred the child to three specialists. At the end of the exam, we thought that it was probably hyperthyroidism, says Iqbal. But there could have been more to it, so we had to do a lot of work. Iqbal charged a 99215-25 and a preventive- medicine services visit.

Note: On the established patient office visit, even if the patient was new, Iqbal billed an established patient on the office visit because he was billing a new patient on the preventive-medicine services visit. He says it is not a good idea to bill both visits for new patients. I dont think you can bill for two new visits, even if theyre on the same day, he says. A patient can only be a new patient once. Also, he didnt want to get into another argument. He wanted to focus on the modifier -25.

He wrote another letter to the CEO of Oxford, saying he was well aware of the policy regarding modifier -25. I wish you would change your policy, he told them, but if you wont, this should be an exception. Again, Oxford reprocessed the claim, and both services were paid.

Case #3: This involves a child with a rare illness. When the child first came in as a new patient, he needed a physical immediately before he could enter school. But at the physical, Iqbal quickly realized that this would be a major time expenditure. The history was long, there were many different physicians in the boys past, there was lab work, speech problems, a swallowing problem and more. It took us over an hour to just go over his illness and plan what we were going to do before we even started with the physical, he says. So much time was involved that other patients had to cancel for that day.

He charged a 99215-25, along with a new patient check-up. The initial claim was denied, and Iqbal filed an appeal, this time with all the documentation in the chart, the documentation of his time spent, plus the copy of the original claim, a copy of the EOB and a letter. I was flabbergasted when I got a brief letter from the medical director of the company, Physician Health Services (PHS), saying that he had talked to a board-certified pediatrician who agrees with their policy of not reimbursing for modifier -25, says Iqbal. The letter went on to say that if a patient has otitis media at the time of the well visit, the board-certified pediatrician and PHS would not honor it. Finally, the letter said that Iqbal was the only pediatrician who had ever complained about this policy.

I didnt know what to do, says Iqbal. Time passed, and I was busy with work. Finally, Iqbal wrote a response to PHS saying, among other things, that the problem wasnt otitis media, and he didnt know where that came from.

The appeal to PHS is still pending. I dont expect to get anything from them, says Iqbal.

Modifier -25 doesnt work all the time, notes Iqbal. I pick my battles, and I think thats very important, he believes. If I start fighting over every little thing, they wont listen to me. Unfortunately, the overall success rate for modifier -25 is not high, he says. And its frustrating because theres so much work involved with filing an appeal. But, he says, when a payer does respond and you get a reimbursement, the benefit is more than just the money. You get such a sense of accomplishment.

Richard H. Tuck, MD, FAAP, founding member of the AMA RBRVS RUC and a pediatrician at PrimeCare of Southeastern Ohio, thinks Iqbal is definitely on the right track. I admire and applaud his persistence with the -25 modifier, says Tuck. This is what all pediatricians should be doing, because the more we do it, the more likely the insurance companies are to accept it.