Pediatric Coding Alert

Question: On claims involving 99381-99385, 99391-99395 and 99201-99215, may we append modifier 25 to the well-check code instead of to the sick visit code?

Ohio Subscriber

Answer: No. You can’t append the modifier interchangeably. If a physician encounters an abnormality(ies) or addresses a pre-existing condition when performing a preventive medicine service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, you should also report the appropriate office/outpatient code 99201-99215, according to CPT preventive medicine services guidelines. "Modifier 25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the preventive medicine service," the AMA stipulates.

Example: A well-controlled diabetic patient comes in for his 6-year-old established annual physical. The pediatrician spends an additional five minutes beyond the time he usually spends on a 99393 preventive medicine service on diabetes management.

Error averted: You append modifier 25 to 99212 (Office or other outpatient visit for the evaluation and management of an established patient …) to indicate that at the time of the scheduled preventive medicine service the pediatrician addressed a significant, separately identifiable problem. To identify the separate issue, link 99212-25 to the diabetes diagnosis (such as 250.01, Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled). Link the preventive medicine service (99393, Periodic comprehensive preventive medicine reevaluation and management of an individual … late childhood [age 5 through 11 years) to the routine health check code (V20.2, Routine infant or child health check).

Important: You can, however, sometimes attach modifier 25 to the preventive medicine service code. For instance, to indicate a well check is a significant, separately identifiable E/M service on the same day of a procedure, such as wart treatment (17110-17111, Destruction [e.g., laser surgery, electrosurgery, cyrosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions ...), you would append modifier 25 to 99381-99385 (New patient preventive medicine service) or 99391-99395 (established patient preventive medicine service).