Pediatric Coding Alert

Trace 2 preventive medicine service claims from start to finish

You've identified which CPT code to append modifier 25 to and under which circumstances, but figuring out how to "append" modifier 25 on the HCFA-1500 form is another ballgame.

"Can you actually print an example as it should appear on a HCFA-1500 form?" asks Shoeb Amin, MD, FAAP, with Bloom, Amin and Banker in Haverstraw, N.Y. Here's the step-by-step breakdown:

Claim 1: You perform an established patient preventive medicine service for a 2-year-old boy who has a cough, congestion and fever, says Richard H. Tuck, MD, FAAP, a national pediatric coding speaker and educator. You make a diagnosis of acute otitis media (382.00, acute suppurative otitis media without spontaneous rupture of ear drum). He says to code the encounter as:

• 99392 (Periodic comprehensive preventive medicine reevaluation and management of an individual ...;  early childhood [age 1 through 4 years]); Dx V20.2 (Routine infant or child health check)

• 99213-25 (est pt visit); Dx 382.00.

Action: On the HCFA-1500 form, you should enter:

1. The ICD-9 codes in box 21. Put V20.2 on line 1 (dx 1) and 382.00 on line 2 (dx 2). These diagnoses should numerically match the order of the CPT codes entered in box 24-D.

2. The CPT codes in box 24-D. Because the preventive medicine service is the primary service and the office visit was provided secondary to the preventive, list 99392 on line 1 and 99213 on line 2.

3. Modifier 25 in box D "modifier" after CPT code 99213.

4. In box 24-E, enter the number (1, 2, 3, 4) of the diagnosis code recorded in box 21 that corresponds to this service/procedure. Do not enter the ICD-9 diagnosis code.

Claim 2: During a 4-year-old's annual established patient preventive medicine service, you administer a vision screen using the Snellen chart and hearing screen by pure tone audiometry. Although CPT does not require you to use modifier 25 on well visits performed inconjunction with screenings and developmental testing, the payer you are billing does require modifier 25 on such claims. So you code the encounter as:

• 99392-25 (preventive exam child 1-4 yrs); Dx V20.2 (preventive exam child 0-17 yrs)

• 99173 (vision screening); Dx V20.2

• 92551 (hearing screening); Dx V20.2.
 
Do this: You should report the claim using the HCFA-1500 form as follows:

1. ICD-9: In box 21, put V20.2 on line 1. You will use diagnosis "1" for all three CPT codes in box 24-E.

2. CPT: In box 24-D, list 99392 on line 1, 99173 on line 2, and 92551 on line 3.

3. Modifier: To indicate that the preventive medicine service is significant and separately identifiable from the screenings, enter "25" in box D "modifier" after 99392.