Pediatric Coding Alert

Answer: Because both pediatricians are in the same group, you should bill as if the same physician saw the child in the morning and in the afternoon.

A morning well visit/afternoon sick visit is coded the same as a well visit/sick visit combination. For example, if you are seeing a child for a well visit and discover that the child has had diarrhea for the past two days, requiring that you perform a stool culture and other services that are separate from the well visit, you could bill for both the well visit and the sick visit (99211-99215) with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the sick visit. Link diagnosis code V20.2 (routine infant or child health check) with the well visit, and the appropriate diagnosis code for the condition with the sick visit code.

A likely scenario for the morning-afternoon combination is a more serious, unpredictable condition, such as an asthma attack or a fall. You would file the claim as if both encounters occurred at the same session. Payment is likely to be easier when the child is seen twice at different times of the day, because the sick visit will be more urgent (for example, a severe sore throat would not likely appear suddenly in the afternoon).

Some practices code a single evaluation and management code rather than bill both the well and sick visits. Billing both procedures using modifier
-25, however, more accurately reflects the work performed. Many commercial payers are now recognizing modifier -25 claims, and those that dont should be encouraged by providers to do so. If your claim is denied, pursue an appeal. Be sure to include all supporting documentation, including the times of each visit, and a copy of the descriptor of modifier -25 in Appendix A of the CPT manual.