Pediatric Coding Alert

Question: Should I append a modifier to a preventive medicine service code? For instance, the pediatrician removes wax from the patient's ear or performs a spirometry for a stable asthmatic during a well checkup.

Missouri Subscriber

Answer: When a pediatrician provides a preventive medicine service (99391-99394) and a minor procedure during the same visit, you should report both items and append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. Although a modifier is technically unnecessary, many insurers require modifier -25 to differentiate the well visit from the procedure. Therefore, using modifier -25 will alleviate reimbursement hassles.

CPT also allows reporting an office visit (99211-99215) in certain situations. If the physician addresses a problem that is significant enough to require additional work to perform the key components of a problem-oriented E/M service, you may also report 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient) appended with modifier -25.

In the two examples that you give, the minor procedures are probably not significant enough to bill an office visit and a preventive medicine service. Suppose a 4-year-old established patient presents for a well visit. During the visit, the mother complains that the child doesn't hear well. The doctor detects cerumen and removes it. In this case, 99392 (Periodic comprehensive preventive medicine reevaluation 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; early childhood [age 1 through 4 years]) would cover the minimal work involved in diagnosing impacted cerumen and deciding to treat it. So, you should report 99392-25 and 69210 (Removal impacted cerumen [separate procedure], one or both ears).

The same work value applies to the spirometry example. The work involved in deciding to take a reading is not enough to support a separate E/M code in addition to the preventive medicine service. Therefore, you would bill only a well visit (99392-25) and spirometry (for example, 94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation).

When you bill multiple services and procedures, as in this scenario, appropriate diagnostic coding linkages are crucial to payment. You should link the preventive medicine service (99392) to the proper V code (V20.2, Routine infant or child health check). If the pediatrician removes cerumen (69210), you should report a diagnosis of impacted cerumen (380.4). Or, if he performs spirometry (94010), assign the appropriate asthma diagnosis (493.00, Extrinsic asthma without mention of status asthmaticus or acute exacerbation or unspecified).

Answers to You Be the Coder and Reader Questions provided by Victoria Jackson, administrator and chief executive officer of Southern Orange County Pediatric Association and owner and executive director of OMNI Management Inc., a medical practice management and billing company.