Pediatric Coding Alert

Question: A consultant suggested we use modifier 25 to overcome denials for 99173 and 81003 with the same-day well child check (WCC). But doesn't the WCC include the vision screen?


Pennsylvania Subscriber

Answer: No. A vision screen (99173, Screening test of visual acuity, quantitative, bilateral) is not performed with every 99382 (Initial comprehensive preventive medicine evaluation and management of an individual ... early childhood [age 1 through 4 years]) and 99392 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... early childhood [age 1 through 4 years]). Further, CPT specifically says, "... ancillary studies involving laboratory, radiology, other procedures, or screening tests identified with a specific CPT code are reported separately" (Preventive Medicine Services introductory notes).

Use the CPT verbiage to challenge 99173 and 81003 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy) with 99382 or 99392 bundles.

Do this: Check whether your major payers want modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) with the E/M service or modifier 59 (Distinct procedural service) with the vision screen/urinalysis. CPT does not require modifier 25 when you bill an E/M service in addition to a screening and/or lab service. But insurers' software edits may expect a modifier, making modifier 25 necessary on 99382 or 99392.

The modifier correctly represents the preventive medicine service as significant, separately identifiable from a screening test or lab. These ancillary studies are separate and not included in the relative value units for the preventive medicine services. Other plans may want modifier 59 on 99173 or 81003 to designate the screening or lab as distinct from the preventive medicine service.

Payment update: The 2007 National Physician fee schedule assigns 99173 a valid RVU value--0.07 transitional non-facility total relative value units representing practice expense, which further legitimizes separately billing the procedure. If you're using the 2007 RVU data for your contracts, make sure you get paid for the screening (expect a minimum of $2.65: 0.07 RVUs x 37.8975 2007 Medicare conversion factor).

Answers to You Be the Coder and Reader Questions answered/reviewed by Joel Bradley Jr., MD, FAAP, a pediatrician with Premier Medical Group in Clarksville, Tenn.; Chip Hart, director of Physician's Computer Company Pediatric Solutions consulting group; Robin Linker, CPC, CPC-H, CCS-P, CPC-P, MCS-P, CHC, chief executive officer of Robin Linker & Associates Inc. in Aurora, Colo.; Charles Scott, MD, FAAP, a pediatric coding expert who practices with Medford Pediatric & Adolescent Medicine in New Jersey; and Richard H. Tuck, MD, FAAP, a national pediatric coding speaker and educator.