Pediatric Coding Alert

Question: Staff sometimes includes modifier 25 on a preventive medicine service code involving immunizations. We are not receiving denials using either method. Per CPT rules, which way is correct?

Missouri Subscriber

Answer: On claims involving a preventive medicine service, immunization administration, and vaccines, CPT does not require you to use modifier 25 (Significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on 99381-99395 (Preventive Medicine Services). If a significant separately identifiable Evaluation and Management service (e.g., office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes, according to CPTs Immunization Administration for Vaccines/Toxoids introductory notes. CPT includes the same instruction in the Vaccines, Toxoids guidelines.

If a payer, however, does require modifier 25 on the preventive medicine service code such as 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual &) to distinguish the service from 90465-+90474 (Immunization Administration for Vaccines/Toxoids), you may follow the insurers individual instruction. Be sure to have the policy in writing to protect your practice in the event the payer questions your modifier use which is not consistent with CPTs guidelines.