Pediatric Coding Alert

Question: When a problem is discovered during a well-child visit, the -25 modifier goes on the evaluation and management (E/M) procedure code. But what about performance of an additional service during a well-child visit (e.g., a vision screening). Should the -25 modifier go on the preventive medicine code?

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Answer: When performing a well visit and finding a separate and identifiable problem for which treatment is provided and documented separately in the chart, you attach modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code, not the preventative medicine code. When performing additional services during the course of any visit, whether it be well or sick, you place the -25 on the office code, regardless of a physical code or E/M code.

Remember that documentation is extremely important for justification of the modifier used in any instance. Some coders believe that there should be a separate diagnosis code linked to the E/M, although this is not required by CPTs definition of modifier -25. Ideally, the -25 modifier is added to the E/M services code whenever a procedure is performed on the same date of service. A procedure, by CPT definition, is any code in the 20000 to 60000 series. The 70000 series covers radiology, the 80000 series covers laboratory, and the 90000 series covers general medicine.
A -25 modifier is not required when radiology, laboratory, or medicine services are performed on the same date of service as the office visit. There is nothing wrong, however, with adding a -25 modifier to the E/M code if this helps the claim go through.

Answers to You Be the Coder and Reader Questions provided by: Thomas Kent, CPC, CMM, president, Kent Medical Management, a coding and practice management firm, Dunkirk, Md.; Richard H. Tuck, MD, FAAP, member, AAP coding and reimbursement committee, practicing pediatrician, Zanesville, Ohio; Victoria Jackson, chairwoman, pediatric task force committee, MGMA administrator/CEO, Southern Orange County Pediatric Associates, Lake Forest, Calif.; Barbara Cobuzzi, CPC, CHBME, president, Cash Flow Solutions Inc., a coding and reimbursement consulting firm, Lakewood, N.J.; Charles Scott, MD, FAAP, a pediatric coding expert who practices with Medford Pediatric & Adolescent Medicine in Medford, N.J.; Mark S. Reuben, MD, FAAP, president, Reading Pediatrics, a private eight-pediatrician practice in Wyomissing, Pa.