Pediatric Coding Alert

Question: Some coders suggest using modifier 25 on the well visit code when also coding 96110. Others recommend appending modifier 59 to 96110 while also coding for the well visit. Which is the proper way?

Florida Subscriber

Answer: Some private payers require modifier 59 (Distinct procedural service) on a procedure code to designate it as distinct from an E/M service. Therefore, you may have to report modifier 59 on the development screening (96110, Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) and no modifier on the preventive medicine service code (such as 99392, Periodic comprehensive preventive medicine reevaluation and management of an individual & early childhood [age 1 through 4 years]). Per CPT, however,the correct submission is to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service) on the preventive medicine service code and not modifier 59 on the developmental testing code.

In 2008, CPT changed modifier 59s description in Appendix A to specify that modifier 59 should only be used to designate a procedure is distinct from another procedure, not to indicate a procedure is distinct from an E/M service as had previously been allowed. Some payers, however, follow modifier 59s old definition and have software edits that automatically reject any claim containing an E/M and a procedure, unless modifier 59 is appended to the procedure. Modifier 59 is always considered a modifier of last resort, in other words when other modifiers are not appropriate for the described circumstance.

To protect your monies in the event the insurer later questions your modifier usage, follow these two best practices:

Tactic 1: Maintain written copies of your major payers modifier 59 and modifier 25 policies. For instance, include a copy of United HealthCares modifier 59 policy, available online, which specifies the insurer follows modifier 59s old definition in your compliance manual.

Tactic 2: If a payers modifier policy is not available -- or if you have always submitted modifier 59 on a procedure to an insurer -- act preemptively.Send a letter or email communication to your payer indicating, Unless we hear otherwise from you within the next 30 days, in accordance with CPT 2007s modifier 59 definition we will continue to submit modifier 59 on a procedure code to indicate it is distinct from an E/M service.

--  Information for and answers to You Be the Coder and Reader Questions reviewed by Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.