Pediatric Coding Alert

Question: We often administer vaccines when we see patients for well baby visits. Do we need to append modifier 25 to the preventive medicine code?

Montana Subscriber

Answer: No, you do not need to include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on your claim. Simply report the vaccine administration code such as 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) or +90472 (... each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure]).

Also report the appropriate preventive medicine code, such as 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant [age younger than 1 year]).

Exception: You will need modifier 25 on the associated E/M code (99212-99215) if the parent brings the baby for a well check and you discover the child is ill.