Pediatric Coding Alert

Green-light E/M with vaccine, circ when documentation supports separate service Just because auditors are targeting modifier 25 doesn't mean you should cut out your use of this tool. These pediatric scenarios do merit its use.
 
Recent reports of the Office of Inspector General (OIG) targeting claims containing modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) have raised concern in pediatric practices. Meeting speakers often warn that overusing modifier 25 is a flag for audit, says Roxanne Warren, a biller at Pediatric Associates in Reno, Nevada. "A large percentage of our claims involve modifier 25," she says. Will that put our practice under scrutiny? she asks.
 
"Every coder should always be concerned and reverent when using modifiers 25," says John F. Bishop, PA-C, CPC, president, of Bishop & Associates Inc. in Tampa, Fla. "The OIG has really cracked down on this modifier and collected huge sums of money for inappropriate coding."
 
Silver lining: One expert allays your fears about using modifier 25 in two common pediatric scenarios. Do: Append 25 When Payer Requires It Insurance companies may require modifier 25 when you report a well-child exam (99391, Periodic comprehensive preventive medicine reevaluation and management of an individual ...; infant [age under 1 year]) and vaccine administration (90465, Immunization administration under 8 years of age [includes percutaneous, intradermal, subcutaneous, or intramuscular injections] when the physician counsels the patient/family; first injection [single or combination vaccine/toxoid], per day), says Bonnie Palmer, billing manager at Tots N Teens Health Associates in Hoffman Estates, Ill. "Is using modifier 25 in this instance appropriate?" she asks.
 
The answer: "It is OK to use modifier 25 with an associated E/M visit and vaccine administration," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. But this is not necessary, based on CPT guidelines , he says.
 
From the horse's mouth: In fact, the AMA acknowledges that there is nothing in CPT that makes modifier 25 on 99391 with 90465 necessary, Tuck says, citing CPT Assistant April 2005, which states, "Payers may require modifier 25 be appended to an E/M service to distinguish it from the vaccine administration." Best bet: Let the insurer determine the modifier's use. Do: Code for Documented Separate E/M With Vaccine Because coding 99391-25, 90465 is not in itself a red flag, the more important issue is whether documentation supports a separate exam. The physician must document "a separate identifiable service above and beyond what is considered inclusive in the procedure," says Sherry Wilkerson, RHIT, CCS, CCS-P, coding/compliance manager at CHAN Healthcare Auditors in St. Louis.
 
The major conclusion of the OIG study was not that modifier 25 was simply inappropriate. "Medical reviewers [...]