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Pediatric Coding Alert

Reader Question:

Report Preventive, E/M Services Separately With Modifier -25

Published on Fri Jan 02, 2004

Question: An established patient of high-school age came in for a sports physical early one morning. That afternoon, in his first basketball practice, he suffered a fall that required a return to our office for examination. Is this a situation in which I could use modifier -25, and if so, how?

Indiana Subscriber
 
Answer: Many carriers balk at having to pay for two E/M services on the same day, but you should be able to garner payment for both of these services using modifier -25.
 
First, list the proper preventive services CPT code from the 99391-99393 group with a diagnosis code of V70.3 (Other medical examination for administrative purposes) for the "well visit" (the sports physical).
 
Report the "sick visit" (the E/M exam for the fall) second, choosing the appropriate-level code from the 99211-99215 group with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to designate that the service is separate from the "well visit." Make sure you include diagnosis codes for the problems the pediatrician treated during the office visit.
 
To maximize payment potential, make sure the pediatrician keeps notes on the two visits separate. One effective way of doing this is to first draw a line at the bottom of the physical-exam sheet. Then document the history, exam and medical-decision making relevant to the fall below this line.
 
Whether you use this method or come up with your own, be sure the "well visit" and its supporting documentation are easily distinguished from the "sick visit" and its supporting documentation.
 
Also, make sure you have attached thorough and accurate ICD-9 coding wherever possible to strengthen your claim.

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