Pediatric Coding Alert

Question: A 14-year-old presented for an annual physical. During the preventive exam, the mother mentioned that her daughter's attention deficit disorder (ADD) medication wasn't working. The physical turned into an ADD re-evaluation. I billed 99394 and 99214-25 with correct diagnosis. The payer denied 99214. How could I get paid for both services?

New York Subscriber

Answer: You correctly billed the encounter. You reported the age-appropriate preventive medicine service for a 14-year-old, 99394 (Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, established patient; adolescent [age 12 through 17 years]), plus an office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient ...) for the problem-related history, examination and medical decision-making service.

To identify the significant, separately identifiable nature of the office visit, you appended modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99214. You should have also linked the preventive diagnosis (V20.2, Routine infant or child health check) to 99394 and the ADD ICD-9 code (314.0x, Attention deficit disorder) to 99214-25.

CPT supports your billing both E/M services. When a physician addresses a pre-existing problem during a preventive medicine service, you may report the appropriate office outpatient code and append with modifier -25, according to CPT's preventive medicine services' notes. To bill 99201-99215-25, the problem must be significant enough to require additional work to perform the key components of a problem-oriented E/M service.

Assuming the pediatrician documented a separate history, examination and medical decision-making for the ADD re-evaluation, you should appeal the office visit denial. With your appeal, submit a copy of CPT's preventive medicine services notes. In your cover letter, inform the insurer that you coded the encounter based on correct coding principles and expect the company to pay appropriately.

Not all insurance companies, however, will pay for two services performed during the same encounter. Some insurers may point to contract clauses to justify not paying for the office visit. If a payer's contract states that the insurer will pay for only one E/M visit per day, you have little grounds for appeal.

If the insurer's contract, in your case, contains a one-daily-E/M clause, you may be able to bill the patient for the service. Check whether the payer states that a second E/M is a noncovered service. In this case, you can bill the patient for 99214-25. On the other hand, if the insurer includes the second E/M in the primary service, you'll have to write off the office visit.

To avoid billing the patient or writing off the problem-related service, you could have the mother and child return for a separate E/M visit to address the ADD problem. Although this ensures the payer won't bundle 99214-25 into 99394, you and the parent may not like the inconvenience a second visit imposes.

-- Answers to You Be the Coder and Reader Questions provided by Joel Bradley Jr., MD, FAAP, a member if the AMA CPT advisory committee and a pediatrician at Premier Medical Group in Clarksville, Tenn.; Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president/CEO of Cash Flow Solutions  in Brick, N.J.; Patricia L. Larabee, CPC, CCP, coding specialist at InterMed in South Portland, Maine; and Jeffrey Linzer Sr., MD, MICP, FAAP, American Academy of Pediatrics representative to the ICD-9-CM editorial advisory board.