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 found that providers did not document the E/M services and/or procedures for 27 percent (116/431) of the sampled claims received from providers," Wilkerson says.
 
For example, documentation for one of the records reviewed indicated that a Medicare beneficiary presented for a flu shot. The provider submitted a claim for the flu shot (90465-90474, Immunization administration ... with 90655-90658, Influenza virus vaccine ...) and a modifier 25-appended E/M service (such as 99381-99397, Preventive medicine service). Both claims were allowed. Problem: The provider furnished documentation that a flu shot was provided, but there was no documentation to support the claim for a separate E/M service.

Lesson learned: When reporting 99391-25 and 90465, "the pediatrician should document all the required elements for the well-child E/M service in addition to documentation of the immunizations provided," Wilkerson says.
 
Good news: Don't worry about the number of claims that you file for combination preventive medicine service and immunization administration. "This type of encounter is common in a pediatric office," Wilkerson says. "If your third-party payers require you to submit modifier 25 on the well-visit code, you are going to have a lot of claims with modifier 25 on the E/M code."

Do: Use 25 When 99431, 54150 Note Has 2 Entries

A similar caveat applies to newborn examination with circumcision coding. "When we do a newborn exam in the hospital (99431, History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records [this code should also be used for birthing room deliveries]) and a circumcision (54150, Circumcision, using clamp or other device; newborn) on the same day, we separate the E/M with  modifier 25," Warren says.
 
Once again, using modifier 25 on a claim for 99431 and 54150 is not in itself incorrect. "It is appropriate to append modifier 25 on the E/M service as long as there is sufficient documentation that the physician performed a separate E/M service," Wilkerson says.
 
To minimize your risk of E/M service repayment requests, the medical record for a claim containing 99431-25 and 54150 should contain these two items:

 • complete documentation of the newborn examination

 • a separate procedure note for the circumcision.

Want more? Upcoming issues of Pediatric Coding Alert will feature modifier 25 and modifier 59 scenarios that your peers have submitted. Have a modifier mystery you want our experts to solve? E-mail the example to the editor at jgodreau@medville.com.
 
Garner more advice by enrolling in The Coding Institute's audioconference "The Scary Truth About Modifier 25 and 59 Misuse: Is Your Practice at Risk?" Find out how misuse has been flagged and make sure your practice is following proper modifier guidelines to stay out of payer scrutiny.