Pediatric Coding Alert

Question: Does a pediatrician have to treat a new problem in order to bill a modifier -25 visit?

California Subscriber

Answer: No. A pediatrician may report an E/M code (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient) appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when treating an existing condition. The key is the physician must perform a separate, significant service from another service or procedure. The stand-alone service must include a history, evaluation and treatment.
 
Example: A pediatrician performs an established patient preventive medicine service on a 12-year-old diabetic. In addition to performing an age-appropriate exam, the physician takes a history and evaluates the patient's diabetes. She determines that the patient's condition is controlled and that his insulin intake is at the appropriate level.
 
Because the problem-related history, examination and treatment plan can stand alone, you would report the above scenario with an office visit code, as well as the preventive medicine service (99394, Periodic comprehensive preventive medicine re-evaluation and management of an individual ...). You would append modifier -25 to the appropriate-level established patient office visit code (such as 99213).