Pediatric Coding Alert

Question: Our pediatrician performed a well visit along with an ocular vision screen on a 3-year-old patient. I want to code 99392 with 99174. My questions are these: do I use modifier 59 and, if so, which service would take the modifier?

California Subscriber

Answer: There should be no need for a modifier in this situation. Per National Correct Coding Initiative (NCCI) edits, 99174 (Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report) is not a column 2 code for 99392 (Periodic comprehensive preventive medicine reevaluation and management of an individual … early childhood (age 1 through 4 years)), so it does not need to be unbundled from the preventive service.

However, if you are dealing with a private payer who does not recognize NCCI edit pairs but who does require a modifier in this situation, modifier 59 (Distinct Procedural Service) would not be the correct modifier to use. Modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) appended to the evaluation and management (E/M) service in the edit pair — in this case, the 99392 preventive visit — would be the correct way to document this encounter.