Pediatric Coding Alert

Question: We recently provided a preventive medicine evaluation and management (E/M) service to a 13-year-old patient as a part of the patient’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit through Medicaid. Additionally, we provided a flu immunization. Our state requires that we use modifier EP for EPSDT services. Does that mean we should use that instead of modifier 25 on the preventive medicine service?

Illinois Subscriber

Answer: EPSDT services require the modifier EP (Service provided as part of Medicaid early periodic screening diagnosis and treatment (EPSDT) program) to be appended to the preventive medicine code, but that does not override the 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) that will go on the 99394 (Periodic comprehensive preventive medicine reevaluation and management of an individual …; adolescent (age 12 through 17 years)), which is required per National Correct Coding Initiative (NCCI, or CCI) edits when you administer an additional service such as an immunization during a preventive medicine exam.

Instead, you should append both modifiers to the 99394 in this instance. And while neither NCCI or Medicaid specify the specific order in which you should place the modifiers, the American Academy of Pediatrics recommends the following:

       99394 25 EP

(Source: www.aap.org/en-us/professional-resources/practice-transformation/getting-paid/Coding-at-the-AAP/Pages/FAQ-Medicaid-NCCI.aspx)