Pediatric Coding Alert

Remember that modifier 25 can separate edits when appropriate.

Dealing with Correct Coding Initiative (CCI) edits can take up hours of your time, particularly in cases when you didn’t know specific services were bundled. You can prevent denials and collect your reimbursement faster if you institute policies now to head off these common pediatric CCI issues up-front.

Keep this in mind: Before you start reviewing CCI edits, remember that not all payers utilize CCI, says Linda R. Farrington, CPC, CPMA, CPC-I, CRC, owner, instructor and consultant with Medisense. “It was originally developed for use by Medicare but has been adopted for use by some commercial payers,” she says. “Some payers have created their own, unique bundling edits. So, depending on the payer, you would want to apply the bundling edits that they would be using to adjudicate the claim.”

1. Don’t Forfeit Vaccine Payments

In 2013, the CCI instituted an edit that bundles well child visit codes 99381-99385 and 99391-99395 into the vaccine administration codes (90460-90461 and 90471-90474). Although at the time, many coders thought the bundle was a mistake, it continues to remain on the books three years later, and doesn’t appear to be on its way out.

The bundles have a modifier indicator of “1,” and the well child visit is listed as the “column two code,” which means that it is the bundled code. Therefore, if you don’t add a modifier to your claim, you will collect for the vaccine administration but you’ll face denials for the well child visit code.

Solution: Currently, you must append a modifier such as 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) to the well child code when you report it with the vaccine administration code. You won’t need to append a modifier to the vaccine code since it is the “column one” or “primary” code.

AAP advice: On its Web site, the American Academy of Pediatrics likewise has recommended the use of modifier 25 on this bundle, “but only when the E/M service is significant and separately identifiable,” the AAP says.

Sick Visit Codes Also Impacted: Although pediatricians are more likely to administer vaccines at a well child visit, you probably also give them at sick visits (99201-99215) from time to time. Unfortunately, the CCI bundle does extend to sick visits as well, and these codes also bundle into the vaccine codes, which means you’ll be busy appending modifier 25 to your sick visit codes as well when you provide those services with immunization administrations.

Double modifier use: If you perform a medically necessary additional E/M service provided with a well child visit and immunizations, you will append modifier 25 to both the well child visit and the sick visit code. This can feel wrong to many practices to use two 25 modifiers on the same claim, but it will be correct coding and it does follow the CCI edits.

2. Look to Modifiers for Nebulizer Treatments

Likewise, if you report a nebulizer treatment (94640) with an E/M visit, your E/M service will also be denied because CCI version 20.0 bundled all of the problem-oriented office visit codes (99201-99215) into the nebulizer code 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device). 

This means that your payer will deny the E/M service for these claims. Fortunately, the edit has a modifier of “1,” which means you can report the two services together if you can prove that the E/M visit was medically necessary and separately identifiable from the nebulizer treatment, and you append modifier 25 to the E/M service.

This will also be the case with 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation), 94620 (Pulmonary stress testing; simple [eg, 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry]) and 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration), all of which have E/M codes bundled into them, but can be billed with a 25 modifier on the E/M code if your documentation demonstrates the medically necessary, separate E/M service.  

Likewise, if you report 94640 and 94664 (teaching on a metered dose inhaler or nebulizer when performed separately), the CCI edit has a “1” indicator, which means you can report both but you have to modify the 94664 with a 59 modifier. Again, remember that this teaching is not done when giving a nebulizer during the visit, but is separate and will need to be documented appropriately.

3. Avoid Modifiers for E/M With Pediatric Critical Care

Not all of the CCI edits allow you to simply use a modifier to untangle the codes, unfortunately. For instance, the indicator is “0” (meaning the edit cannot be separated under any circumstances) for the edits bundling subsequent hospital care codes 99231-99233 into the daily inpatient neonatal/pediatric critical care codes 99468-99476.

Example: Suppose the pediatrician is doing rounds on an established infant inpatient. He evaluates a patient and determines that she requires critical care. In this instance, he should only report the critical care code and not the subsequent inpatient E/M for that visit.

When you see a ‘0’ edit, you’ll report the column 1 code and not the column 2 code. It is the more extensive service and includes what you would have performed for the column 2 code.