Pediatric Coding Alert

Question: We have many patients with ADD or ADHD. We do yearly exams on these children, and we bill using a well visit code. Should we report modifier 25 on these visits for the ADD? Also, when the parents pick up the monthly prescription, should we charge a copay?

Texas Subscriber

Answer: You don’t need to append modifier 25 (Significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified healthcare professional on the day of a procedure) if the only CPT^® code you’re reporting is a well child visit. The diagnosis of ADD won’t necessarily warrant any additional services, and if the child has already been diagnosed with ADD and you’re performing an annual physical and not addressing the ADD, then you’ll only report the well child code.

If, however, you bill a well visit along with a problem-focused visit that focuses on the ADD, you should add modifier 25 to the sick visit code, but some insurers (particularly certain Medicaid carriers) want modifier 25 on the well visit code instead, so check with your insurer’s preferences before billing.

If the parent just shows up for the medication refill prescription, you should not charge a copay since no face-to-face service between the patient and provider took place. If, however, there is a brief, medically necessary face-to-face visit with a nurse (99211) or physician (99212 or 99213), a copay will apply and should be collected.