Wiki Modifier -25 - identifiable issue

[cperk]

This is a recent subject of debate in my office. A NEW patient is seen for a preventive visit. 99381. A significant and separately identifiable issue is addressed. Would you a new or established patient code in instance for the modifier? Does the number of key elements affect whether or not it would be new or not?

Cliff Perkins
CPC Rady Children's Physicans Managed Care Services

 

[krisw7067]

Modifier -25

Are you saying you have a new patient coming in for the first time and they are getting their well visit. There is a totally different topic that has nothing to do with their well visit discussed, are you asking if you should add the new patient e/m too (99203) also with well visit???

Kris

 

[cperk]

Are you saying you have a new patient coming in for the first time and they are getting their well visit. There is a totally different topic that has nothing to do with their well visit discussed, are you asking if you should add the new patient e/m too (99203) also with well visit???

Kris

Yes Kris. In our debate it's a newborn's first well visit. Never seen the provider or anyone from this practice. The question is, if in the course of that visit a problem is discovered that goes beyond the aspect of a normal well visit. The well visit will be coded 99381 for a new patient preventive visit. In addressing the significant and separately identifiable problem discovered during the visit, would that be coded with an established patient code with a modifier 25 or a new patient E/M code with a modifier 25?

 

[krisw7067]

Modifier -25

Insurance will NOT pay for a new well visit and an new office visit on the same day we have tried it with the modifier. What can be so significant on a newborn visit that can't be bundled into a well visit? If it is jaundice it is rolled into the visit.

 

[cperk]

Insurance will NOT pay for a new well visit and an new office visit on the same day we have tried it with the modifier. What can be so significant on a newborn visit that can't be bundled into a well visit? If it is jaundice it is rolled into the visit.

There are several instances and several examples in which a signifcant issue is discovered during an initial visit. Not really concerned about what insurance will pay for. Our concern is compliant coding. Everyone here understands that jaundice, some weight loss, etc.. is expected. Maybe you didn't understand the question. Thanks anyway.

 

[mitchellde]

Kris this where ICD-10 CM will be very helpful... The codes address a preventive encounter with an abnormal finding... Now the affordable care act says that if the reason for the encounter is primarily preventive then you cannot have a separately identifiable office visit. This is why this particularly problematic for a new patient preventive.. So I suggest you use the 33 modifier... In other words do not bill the preventive, use a new patient visit level, for the entire encounter, it will be a high level, append the 33. The 33 modifier identifies the service as meeting the task force A/B definition but contains a diagnostic part... In this way the patient will not owe the co-pay. However to address your original question, and you may not like this...
There are wholly two different schools of thought
1 - the patient is new on both counts so you bill both as new if the patient comes for a preventive and has a symptomatic concern ( only until ICD-10CM)
2 - the patient is new for the preventive they came in for and established for the next encounter for the symptomatic piece, since you could have performed on two separate days.